Provider Demographics
NPI:1346298205
Name:GREGORY, DAVID D (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 HUNTERS TRL
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3429
Mailing Address - Country:US
Mailing Address - Phone:608-724-7161
Mailing Address - Fax:608-745-3060
Practice Address - Street 1:2825 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3429
Practice Address - Country:US
Practice Address - Phone:608-724-7161
Practice Address - Fax:608-745-3060
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23436-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346298205Medicaid
WIK400176502Medicare PIN
WI080108629Medicare PIN
WI000313215Medicare PIN
WI9315OtherDEAN HEALTH INSURANCE
WI30217200Medicaid
WI080114669Medicare PIN