Provider Demographics
NPI:1629064910
Name:MIMS, GREGORY S II (MD)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:MIMS
Suffix:II
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 1:492 SUNSET BEACH RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4424
Mailing Address - Country:US
Mailing Address - Phone:541-331-1225
Mailing Address - Fax:
Practice Address - Street 1:13833 TAPIA AVE
Practice Address - Street 2:
Practice Address - City:BAYOU LA BATRE
Practice Address - State:AL
Practice Address - Zip Code:36509-2515
Practice Address - Country:US
Practice Address - Phone:251-824-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069739L207Q00000X
WV23477207Q00000X
ALMD.29861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABM6805937OtherDEA
PABM6805937OtherDEA