Provider Demographics
NPI:1629237789
Name:SMALL, GREGORY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:SMALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 TEXAS STATION COURT
Practice Address - Street 2:SUITE 210
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-683-3380
Practice Address - Fax:410-683-3121
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD72359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD712L/ 231210YBPGMedicare PIN