Provider Demographics
NPI:1942289962
Name:GREGORY, RICHARD DONALD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DONALD
Last Name:GREGORY
Suffix:
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 1:1377 E HERNDON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3022
Mailing Address - Country:US
Mailing Address - Phone:559-450-7455
Mailing Address - Fax:559-450-7473
Practice Address - Street 1:1377 E HERNDON AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3022
Practice Address - Country:US
Practice Address - Phone:559-450-7455
Practice Address - Fax:559-450-7473
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75677208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G756770Medicare PIN
G48748Medicare UPIN