Provider Demographics
NPI:1164716734
Name:NIECKULA, GREGORY J (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:NIECKULA
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:1238 TAFT HIGHWAY
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3295
Mailing Address - Country:US
Mailing Address - Phone:423-886-2004
Mailing Address - Fax:423-886-7803
Practice Address - Street 1:1238 TAFT HIGHWAY
Practice Address - Street 2:SUITE 170
Practice Address - City:SIGNAL MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37377-3295
Practice Address - Country:US
Practice Address - Phone:423-886-2004
Practice Address - Fax:423-886-7803
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2014-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN2524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005749Medicaid