Provider Demographics
NPI:1043897051
Name:GREGORY, NICHOLAS BLAKE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:BLAKE
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8426
Mailing Address - Country:US
Mailing Address - Phone:517-285-9982
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR RM 4001
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1099
Practice Address - Country:US
Practice Address - Phone:734-712-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty