Provider Demographics
NPI:1598836769
Name:MAKOVIC, GREGG ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ROBERT
Last Name:MAKOVIC
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S AVERILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3813
Mailing Address - Country:US
Mailing Address - Phone:310-548-6298
Mailing Address - Fax:
Practice Address - Street 1:717 S AVERILL AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3813
Practice Address - Country:US
Practice Address - Phone:310-548-6298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2521213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E25210Medicaid
CAE2521Medicare PIN
CA000E25210Medicaid
CA00E2521Medicare ID - Type Unspecified