Provider Demographics
NPI:1548396005
Name:GREGORY, EVA DAUTENHAHN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVA
Middle Name:DAUTENHAHN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 IRVING AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:249 ROUTE 11A
Practice Address - Street 2:
Practice Address - City:NEDROW
Practice Address - State:NY
Practice Address - Zip Code:13120-0000
Practice Address - Country:US
Practice Address - Phone:315-469-6449
Practice Address - Fax:315-469-0593
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F00262Medicare UPIN