Provider Demographics
NPI:1275552499
Name:VESCERA, GREGORY PAUL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:VESCERA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:2295 TOWNE LAKE PKWY STE 148
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5520
Practice Address - Country:US
Practice Address - Phone:770-926-2744
Practice Address - Fax:770-926-2794
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01858225100000X
MA18093225100000X
GAPT013719225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI31122-9OtherBLUE CROSS/BLUE SHIELD
RI050510756OtherUNITED HEALTH
RI007058332Medicare ID - Type Unspecified
RI411731OtherBLUE CHIP