Provider Demographics
NPI:1487648473
Name:WASER, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WASER
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 1:1801 SARNO RD
Mailing Address - Street 2:#6
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3989
Mailing Address - Country:US
Mailing Address - Phone:321-259-6350
Mailing Address - Fax:321-259-1605
Practice Address - Street 1:1801 SARNO RD
Practice Address - Street 2:#6
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3989
Practice Address - Country:US
Practice Address - Phone:321-259-6350
Practice Address - Fax:321-259-1605
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04124OtherBCBS
FL061729600Medicaid
FL04124ZOtherMEDICARE
FL061729600Medicaid