Provider Demographics
NPI:1275761991
Name:HELLER, GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:HELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19389 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6500
Mailing Address - Country:US
Mailing Address - Phone:623-537-6000
Mailing Address - Fax:
Practice Address - Street 1:19389 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6500
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206528204D00000X
AZR1704207Q00000X
AZ006017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR1704OtherTRAINING PERMIT