Provider Demographics
NPI:1588652929
Name:DISALVATORE, GREGORY PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:DISALVATORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1145 S. UTICA AVE.
Mailing Address - Street 2:STE. 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:10502 N 110TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6655
Practice Address - Country:US
Practice Address - Phone:918-376-8190
Practice Address - Fax:918-376-8479
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK500522075OtherMEDICARE GROUP PIN
OK100209670AMedicaid
OKG53981Medicare UPIN
OK500522075OtherMEDICARE GROUP PIN