Provider Demographics
NPI:1295823409
Name:DUNNICLIFF, GREGORY DEAN (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DEAN
Last Name:DUNNICLIFF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2087 GRAND CANAL BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6651
Mailing Address - Country:US
Mailing Address - Phone:209-473-1138
Mailing Address - Fax:209-473-1891
Practice Address - Street 1:2087 GRAND CANAL BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6651
Practice Address - Country:US
Practice Address - Phone:209-473-1138
Practice Address - Fax:209-473-1891
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPT86420Medicare ID - Type UnspecifiedPROVIDER ID