Provider Demographics
NPI:1578644670
Name:URBAN, GREGORY DARYL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DARYL
Last Name:URBAN
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 1:1215 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2102
Mailing Address - Country:US
Mailing Address - Phone:970-255-1720
Mailing Address - Fax:970-255-1745
Practice Address - Street 1:1215 N 1ST ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2102
Practice Address - Country:US
Practice Address - Phone:970-255-1720
Practice Address - Fax:970-255-1745
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29673208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO240006078OtherRAILROAD MEDICARE
CO01296730Medicaid
CO04021788Medicaid
CO01296730Medicaid
CO91631Medicare ID - Type Unspecified