Provider Demographics
NPI:1487762274
Name:PAUL R. GREGORY, JR. MD
Entity type:Organization
Organization Name:PAUL R. GREGORY, JR. MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:916-536-9455
Mailing Address - Street 1:6620 COYLE AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6333
Mailing Address - Country:US
Mailing Address - Phone:916-536-9455
Mailing Address - Fax:916-536-9424
Practice Address - Street 1:6620 COYLE AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6333
Practice Address - Country:US
Practice Address - Phone:916-536-9455
Practice Address - Fax:916-536-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102720Medicaid
CAZZZ02950ZMedicare ID - Type Unspecified