Provider Demographics
NPI:1275050437
Name:STAVARIDIS, GREGORY CHRISTOPHER (NP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CHRISTOPHER
Last Name:STAVARIDIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 HARBOR ST APT 1
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4783
Mailing Address - Country:US
Mailing Address - Phone:303-232-0296
Mailing Address - Fax:
Practice Address - Street 1:2900 E DEL MAR BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-4375
Practice Address - Country:US
Practice Address - Phone:626-795-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006943363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health