Provider Demographics
NPI:1558362467
Name:DAHLQUIST, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DAHLQUIST
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 1:1770 N ORANGE GROVE AVE
Mailing Address - Street 2:SUTIE 101
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3027
Mailing Address - Country:US
Mailing Address - Phone:909-469-9494
Mailing Address - Fax:909-628-6087
Practice Address - Street 1:1770 N ORANGE GROVE AVE
Practice Address - Street 2:SUTIE 101
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3027
Practice Address - Country:US
Practice Address - Phone:909-469-9494
Practice Address - Fax:909-628-6087
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56074207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC0166505OtherDEA #
BC0166505OtherDEA #