Provider Demographics
NPI:1285638254
Name:OLIVER, GREGORY ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:OLIVER
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 1:5645 LAFAYETTE RD STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1103
Mailing Address - Country:US
Mailing Address - Phone:317-387-3050
Mailing Address - Fax:317-295-7044
Practice Address - Street 1:5645 LAFAYETTE RD STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1103
Practice Address - Country:US
Practice Address - Phone:317-387-3050
Practice Address - Fax:317-295-7044
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000756A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
202060AMedicare ID - Type Unspecified
E45889Medicare UPIN