Provider Demographics
NPI:1225046568
Name:MYNKO, GREGORY SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SPENCER
Last Name:MYNKO
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 1:32475 OAK KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-8324
Mailing Address - Country:US
Mailing Address - Phone:951-609-5028
Mailing Address - Fax:951-678-4287
Practice Address - Street 1:32475 OAK KNOLL LN
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-8324
Practice Address - Country:US
Practice Address - Phone:951-609-5028
Practice Address - Fax:951-678-4287
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 74144207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG 74144OtherCA STATE MEDICAL LICENSE
CAG 74144OtherCA STATE MEDICAL LICENSE
CAG 74144OtherCA STATE MEDICAL LICENSE
I02156Medicare UPIN