Provider Demographics
NPI:1467870477
Name:WALLINGFORD, GREGORY N (MD, MBA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:N
Last Name:WALLINGFORD
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 TRINITY ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1765
Mailing Address - Country:US
Mailing Address - Phone:512-324-8933
Mailing Address - Fax:
Practice Address - Street 1:1500 RED RIVER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1918
Practice Address - Country:US
Practice Address - Phone:512-324-8933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460183207P00000X
TXS5290207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine