Provider Demographics
NPI:1326163890
Name:GANZER, GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:GANZER
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 1:2101 CHAPLINE ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3855
Mailing Address - Country:US
Mailing Address - Phone:304-233-3240
Mailing Address - Fax:304-233-4176
Practice Address - Street 1:2101 CHAPLINE ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3855
Practice Address - Country:US
Practice Address - Phone:304-233-3240
Practice Address - Fax:304-233-4176
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1159207N00000X
OH34005620207N00000X
PAOS006564L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0889865Medicaid
WV0042262000Medicaid
OH0889865Medicaid
WV0704421Medicare ID - Type Unspecified
WV0042262000Medicaid