Provider Demographics
NPI:1568997559
Name:ABDULLAH, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ABDULLAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:DEENRAUSAN
Other - Last Name:ABDULLAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RT(R)CT
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:GANADO
Mailing Address - State:AZ
Mailing Address - Zip Code:86505-0778
Mailing Address - Country:US
Mailing Address - Phone:520-604-7560
Mailing Address - Fax:
Practice Address - Street 1:134 E MISTLETOE AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3407
Practice Address - Country:US
Practice Address - Phone:210-223-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17913247100000X
AZ314262471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist