Provider Demographics
NPI:1144924861
Name:GRESHAM, EDWARD A JR
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:GRESHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 LANE ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3848
Mailing Address - Country:US
Mailing Address - Phone:419-359-5303
Mailing Address - Fax:
Practice Address - Street 1:828 LANE ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3848
Practice Address - Country:US
Practice Address - Phone:419-359-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor