Provider Demographics
NPI:1477581221
Name:GREGORY, CHARLES C (DO PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DO PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311B BUDDY GANEM
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-3233
Mailing Address - Country:US
Mailing Address - Phone:361-643-9800
Mailing Address - Fax:361-643-5112
Practice Address - Street 1:311B BUDDY GANEM
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-3233
Practice Address - Country:US
Practice Address - Phone:361-643-9800
Practice Address - Fax:361-643-5112
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7737207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178461302Medicaid
TX8U3260OtherINDIVIDUAL BCBS
TXI44456Medicare UPIN
TX8U3260OtherINDIVIDUAL BCBS
TX8F1727Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE