Provider Demographics
NPI:1629198866
Name:BENTZ, GREGORY D (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:BENTZ
Suffix:
Gender:M
Credentials:MD, PHD
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Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44045 RIVERSIDE PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE - INOVA LOUDOUN HOSPITAL
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5101
Mailing Address - Country:US
Mailing Address - Phone:703-858-8021
Mailing Address - Fax:703-858-8970
Practice Address - Street 1:44045 RIVERSIDE PKWY
Practice Address - Street 2:MEDICAL STAFF OFFICE - INOVA LOUDOUN HOSPITAL
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5101
Practice Address - Country:US
Practice Address - Phone:703-858-8021
Practice Address - Fax:703-858-8970
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF06578Medicare UPIN