Provider Demographics
NPI:1003428574
Name:FORD, GREGORY RAYMON JR
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:RAYMON
Last Name:FORD
Suffix:JR
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 1:5188 CARTER WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7170
Mailing Address - Country:US
Mailing Address - Phone:904-445-7228
Mailing Address - Fax:
Practice Address - Street 1:2702 SCHAUL ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2123
Practice Address - Country:US
Practice Address - Phone:706-641-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9480288163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse