Provider Demographics
NPI:1164621835
Name:GREGG A PEARSON DO PC
Entity Type:Organization
Organization Name:GREGG A PEARSON DO PC
Other - Org Name:WATERFORD FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-561-5900
Mailing Address - Street 1:369 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD WORKS
Mailing Address - State:NJ
Mailing Address - Zip Code:08089-0849
Mailing Address - Country:US
Mailing Address - Phone:609-561-5900
Mailing Address - Fax:609-561-8989
Practice Address - Street 1:369 SOUTH WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WATERFORD WORKS
Practice Address - State:NJ
Practice Address - Zip Code:08089-0849
Practice Address - Country:US
Practice Address - Phone:609-561-5900
Practice Address - Fax:609-561-8989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB72474305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2155351000OtherKEYSTONE
NJ8538808Medicaid
NJ2158351001OtherAMERIHEALTH
NJ2155351000OtherINDEPENDENCE BCBS
NJ051428Medicare PIN