Provider Demographics
NPI:1316025323
Name:GULSO, GREOGRY J (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREOGRY
Middle Name:J
Last Name:GULSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR STE C200
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4973
Mailing Address - Country:US
Mailing Address - Phone:801-294-8266
Mailing Address - Fax:801-294-8265
Practice Address - Street 1:415 MEDICAL DR STE C200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4973
Practice Address - Country:US
Practice Address - Phone:801-294-8266
Practice Address - Fax:801-294-8265
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295236-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5843950001Medicare NSC
UT000012751Medicare ID - Type Unspecified
UT6201940001Medicare NSC
UTV06350Medicare UPIN