Provider Demographics
NPI:1386207231
Name:GREGG, EVAN MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MARSHALL
Last Name:GREGG
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 1:7703 FLOYD CURL DRIVE
Mailing Address - Street 2:RM: 719L.-L5 MC:7792
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-567-5742
Mailing Address - Fax:210-567-3483
Practice Address - Street 1:7703 FLOYD CURL DRIVE
Practice Address - Street 2:RM: 719L.-L5 MC:7792
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3900
Practice Address - Country:US
Practice Address - Phone:210-567-5742
Practice Address - Fax:210-567-3483
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10067914390200000X
VA0101271212208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program