Provider Demographics
NPI:1376865790
Name:SMALL, GREGORY JAMES (CO, LO)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JAMES
Last Name:SMALL
Suffix:
Gender:M
Credentials:CO, LO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7849 ILESON RD
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-4473
Mailing Address - Country:US
Mailing Address - Phone:940-440-9632
Mailing Address - Fax:940-440-9632
Practice Address - Street 1:1935 MEDICAL DISTRICT DR.
Practice Address - Street 2:CHILDRENS MEDICAL CENTER P. M. & R. DEPT
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-456-2778
Practice Address - Fax:214-456-8107
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX157222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist