Provider Demographics
NPI:1265496954
Name:DEFOR, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:DEFOR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-552-2600
Mailing Address - Fax:651-552-2614
Practice Address - Street 1:5625 CENEX DR
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-1724
Practice Address - Country:US
Practice Address - Phone:651-552-2600
Practice Address - Fax:651-552-2614
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2022-07-21
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Provider Licenses
StateLicense IDTaxonomies
MN38410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN067718300Medicaid
G24526Medicare UPIN
MN080021007Medicare PIN