Provider Demographics
NPI:1568430437
Name:DEAN, GREGORY A (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:DEAN
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 233
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-0233
Mailing Address - Country:US
Mailing Address - Phone:660-425-7443
Mailing Address - Fax:660-425-6516
Practice Address - Street 1:2703 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424
Practice Address - Country:US
Practice Address - Phone:660-425-7443
Practice Address - Fax:660-425-6516
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207374505Medicaid
MO207374505Medicaid
I25870Medicare UPIN