Provider Demographics
NPI:1083637540
Name:DAMERY, GREGORY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:DAMERY
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 1:515 CHANNING RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-940-9336
Mailing Address - Fax:888-470-8777
Practice Address - Street 1:515 CHANNING RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-940-9336
Practice Address - Fax:888-470-8777
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0070721207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14534OtherSTAYWELL/WELLCARE
FL216008OtherAMERIGROUP
FL38082AMedicare PIN
FL001255742006OtherUNITED HEALTHCARE
FL38082OtherBCBS
FL258856OtherAVMED
FL4122579OtherAETNA
FLE68608Medicare UPIN
FL252167900Medicaid