Provider Demographics
NPI:1861097826
Name:MEAD, GARY A
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:MEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-3548
Mailing Address - Country:US
Mailing Address - Phone:541-205-5661
Mailing Address - Fax:541-205-5694
Practice Address - Street 1:2526 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3548
Practice Address - Country:US
Practice Address - Phone:541-205-5661
Practice Address - Fax:541-205-5694
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBL001014347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker