Provider Demographics
NPI:1417942681
Name:NEDURIAN, GREGORY L (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:NEDURIAN
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 1:521 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4504
Mailing Address - Country:US
Mailing Address - Phone:863-687-0550
Mailing Address - Fax:863-682-7700
Practice Address - Street 1:521 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4504
Practice Address - Country:US
Practice Address - Phone:863-687-0550
Practice Address - Fax:863-682-7700
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0090819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48466YMedicare ID - Type Unspecified
FLB41836Medicare UPIN