Basic Information
| Provider Information | |||||||||
| NPI: | 1083805006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERTMAN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522225862 | ||||||||
| FaxNumber: | 2522479469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2145 COUNTRY CLUB RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285462404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109395759 | ||||||||
| FaxNumber: | 9109394951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 201101058 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | NC2086 | 05 | SC | MEDICAID | 1083805006 | 05 | NC | MEDICAID |