Provider Demographics
NPI:1649316647
Name:VESCERA, GARY C (HIS)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:C
Last Name:VESCERA
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SUMMITT RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712
Mailing Address - Country:US
Mailing Address - Phone:203-574-5377
Mailing Address - Fax:
Practice Address - Street 1:620 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2767
Practice Address - Country:US
Practice Address - Phone:203-634-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004242632Medicaid