Provider Demographics
NPI:1639526577
Name:GREMILLION, JARED TODD (DPM)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:TODD
Last Name:GREMILLION
Suffix:
Gender:M
Credentials:DPM
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 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-390-3340
Practice Address - Street 1:240 MEDICAL PARK BLVD STE 1500
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7353
Practice Address - Country:US
Practice Address - Phone:423-990-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPOD.INTERN213E00000X
TN857213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist