Provider Demographics
NPI:1174753982
Name:GREDITZER, HARRY GUS IV (MD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:GUS
Last Name:GREDITZER
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4823
Mailing Address - Country:US
Mailing Address - Phone:212-606-1015
Mailing Address - Fax:
Practice Address - Street 1:7733 FORSYTH BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1817
Practice Address - Country:US
Practice Address - Phone:212-606-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009020446207R00000X
FLME1121332085R0202X
MO20150439332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine