Provider Demographics
NPI:1164469912
Name:DENICOLA, GREGG (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:
Last Name:DENICOLA
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 1:18200 YORBA LINDA BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18300 YORBA LINDA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4052
Practice Address - Country:US
Practice Address - Phone:714-577-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G435620Medicaid
CA00G435620Medicaid
CAA49390Medicare UPIN