Provider Demographics
NPI:1154328011
Name:EYRE, GREGORY GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GENE
Last Name:EYRE
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2158 JEAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3412
Practice Address - Country:US
Practice Address - Phone:530-543-5691
Practice Address - Fax:531-542-2872
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83380208600000X
NV10616208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502317Medicaid
CA00A833802Medicare PIN
CA00A833800Medicaid
H95021Medicare UPIN
NVV105541Medicare PIN