Provider Demographics
NPI:1477512291
Name:CONDON, GREGORY JOSEF (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOSEF
Last Name:CONDON
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:PO BOX 1885
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-1885
Mailing Address - Country:US
Mailing Address - Phone:901-725-8920
Mailing Address - Fax:901-725-8934
Practice Address - Street 1:1211 UNION AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-725-8920
Practice Address - Fax:901-725-8934
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000180032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3026721Medicaid
AR158519001Medicaid
TN3026721Medicaid
E89016Medicare UPIN
TN3026721Medicare ID - Type Unspecified