Provider Demographics
NPI:1275506149
Name:DEEM, GREGORY WYETT (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WYETT
Last Name:DEEM
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 1:1010 THREE SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8296
Mailing Address - Country:US
Mailing Address - Phone:970-764-3207
Mailing Address - Fax:970-764-3789
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-3207
Practice Address - Fax:970-764-3789
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-42371207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01064990OtherMCR RAILROAD
CO22405542Medicaid
CO22405542Medicaid
COP01064990OtherMCR RAILROAD