Provider Demographics
NPI:1033116975
Name:STELLA, GREGORY J (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:STELLA
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 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:904-398-3262
Mailing Address - Fax:904-265-4807
Practice Address - Street 1:3635 S CLYDE MORRIS BLVD
Practice Address - Street 2:STE 100
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2300
Practice Address - Country:US
Practice Address - Phone:386-788-1242
Practice Address - Fax:386-788-4255
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-01-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME44104207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270347500Medicaid
FL64517XMedicare PIN