Provider Demographics
NPI:1093034126
Name:THORESON, GREGORY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROBERT
Last Name:THORESON
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:3417 GASTON AVE
Practice Address - Street 2:SUITE 830
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-0830
Practice Address - Country:US
Practice Address - Phone:214-826-6021
Practice Address - Fax:214-823-9745
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4316208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348940302Medicaid
TX348940301Medicaid
TX348940303Medicaid
TX348940303Medicaid
TX430763YNEDMedicare PIN
TX348940302Medicaid