Provider Demographics
NPI:1245220672
Name:ENNIS, GREGORY MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARK
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6401 KIMBALL DR
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1228
Mailing Address - Country:US
Mailing Address - Phone:253-858-9192
Mailing Address - Fax:253-985-2853
Practice Address - Street 1:6401 KIMBALL DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1228
Practice Address - Country:US
Practice Address - Phone:253-858-9192
Practice Address - Fax:253-985-2853
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-12-03
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Provider Licenses
StateLicense IDTaxonomies
WAMD60105263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1366539421Medicaid
WA2040574Medicaid
1366539421Medicare NSC
WA1366539421Medicaid