Provider Demographics
NPI:1164609855
Name:MCFADDEN, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MCFADDEN
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 1:4308 ELLENVILLE PL
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7147
Mailing Address - Country:US
Mailing Address - Phone:813-767-6322
Mailing Address - Fax:
Practice Address - Street 1:3234 S FLORIDA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4564
Practice Address - Country:US
Practice Address - Phone:863-619-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04144Medicare PIN