Provider Demographics
NPI:1013185842
Name:DALENCOURT, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DALENCOURT
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 1:110 HOSPITAL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4019
Mailing Address - Country:US
Mailing Address - Phone:347-712-0528
Mailing Address - Fax:
Practice Address - Street 1:110 HOSPITAL RD STE 101
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4019
Practice Address - Country:US
Practice Address - Phone:410-535-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247251208600000X
IL036141318208600000X
MDD0099371208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400321885Medicare PIN
NY7229H1OtherEMPIRE BC/BS