Provider Demographics
NPI:1649403106
Name:GREGG T. PODLESKI, D.O. P.A.
Entity Type:Organization
Organization Name:GREGG T. PODLESKI, D.O. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PODLESKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PA
Authorized Official - Phone:972-613-7776
Mailing Address - Street 1:PO BOX 851858
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-1858
Mailing Address - Country:US
Mailing Address - Phone:972-613-7776
Mailing Address - Fax:972-613-7775
Practice Address - Street 1:2540 N GALLOWAY AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6306
Practice Address - Country:US
Practice Address - Phone:972-613-7776
Practice Address - Fax:972-613-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7138207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3342342OtherBLUE LINK
TXN35UOtherBLUE CROSS PROVIDER
TX03034994601Medicaid
TX4570998OtherAETNA PIN
TX180405500OtherDOL ACS
TX180405500OtherDOL ACS
TX03034994601Medicaid