Provider Demographics
NPI:1225167281
Name:PETERSBURG, GREGORY WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WAYNE
Last Name:PETERSBURG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10371 N ORACLE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-9392
Mailing Address - Country:US
Mailing Address - Phone:520-229-1900
Mailing Address - Fax:520-742-2900
Practice Address - Street 1:10371 N ORACLE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-9392
Practice Address - Country:US
Practice Address - Phone:520-229-1900
Practice Address - Fax:520-742-2900
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3714207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3714OtherAZ MEDICAL LICENSE
AZ3714OtherAZ MEDICAL LICENSE
AZ79567Medicare ID - Type UnspecifiedSTATE PROVIDER NUMBER