Provider Demographics
NPI:1619934379
Name:STAVISKI, GREGORY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:STAVISKI
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 699
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0699
Mailing Address - Country:US
Mailing Address - Phone:850-243-7788
Mailing Address - Fax:850-243-7738
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1972
Practice Address - Country:US
Practice Address - Phone:850-243-7788
Practice Address - Fax:850-243-7738
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63238174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7290008OtherAETNA
FL44880OtherBLUE CROSS BLUE SHIELD
E1383YMedicare ID - Type Unspecified
FL44880OtherBLUE CROSS BLUE SHIELD