Provider Demographics
NPI:1487648432
Name:WOLGAMOTT, GREGORY A (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:WOLGAMOTT
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 249
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7154
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:1660 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2800
Practice Address - Fax:360-414-2803
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031845207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR65461Medicaid
WA8157463Medicaid
WA081333OtherLABOR & IND.
WA8940265OtherCRIME VICTIMS
WA8157463Medicaid