Provider Demographics
NPI:1861573305
Name:JELLINEK, M.D. INC, C. GREGORY
Entity type:Individual
Prefix:
First Name:C.
Middle Name:GREGORY
Last Name:JELLINEK, M.D. INC
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 1:11209 BROCKWAY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-2218
Mailing Address - Country:US
Mailing Address - Phone:530-587-8600
Mailing Address - Fax:530-587-8606
Practice Address - Street 1:11209 BROCKWAY ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161
Practice Address - Country:US
Practice Address - Phone:530-587-8600
Practice Address - Fax:530-587-8606
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG035646208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46425Medicare ID - Type Unspecified