Provider Demographics
NPI:1023056876
Name:GREGORY, VICTOR H (DO)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:H
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:
Practice Address - Street 1:3680 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8005
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS40692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2001907OtherAETNA HMO
57595OtherBCBS
FL253664100Medicaid
FLOS4069OtherFLORIDA LICENSE
4313421OtherAETNA PPO
2001907OtherAETNA HMO
A15795Medicare UPIN
FL253664100Medicaid