Provider Demographics
NPI:1184687675
Name:GREGORY, DOUGLAS BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BLAIR
Last Name:GREGORY
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:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3525
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:4868 BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2048
Practice Address - Country:US
Practice Address - Phone:757-483-7900
Practice Address - Fax:757-483-7151
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032733208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006715630Medicaid
VA006715630Medicaid