Provider Demographics
NPI:1639365273
Name:DEACON, GREGORY S (CP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:DEACON
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
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Mailing Address - Street 1:4338 WILLIAMSON RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-2821
Mailing Address - Country:US
Mailing Address - Phone:540-366-8287
Mailing Address - Fax:540-366-3050
Practice Address - Street 1:315 HOSPITAL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1945
Practice Address - Country:US
Practice Address - Phone:276-634-5690
Practice Address - Fax:276-634-5691
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2014-05-14
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795211Medicaid