Provider Demographics
NPI:1164551594
Name:KOTHEIMER, GREGORY CONRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CONRAD
Last Name:KOTHEIMER
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 1:3728 SOUTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1707
Mailing Address - Country:US
Mailing Address - Phone:903-595-7349
Mailing Address - Fax:903-593-1966
Practice Address - Street 1:1 LOWER NAVY HILL
Practice Address - Street 2:
Practice Address - City:GARAPAN
Practice Address - State:SAIPAN
Practice Address - Zip Code:96950
Practice Address - Country:UM
Practice Address - Phone:670-285-2626
Practice Address - Fax:670-236-8600
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP0410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24091Medicare UPIN