Provider Demographics
NPI:1659347789
Name:BATHURST, GREGORY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOSEPH
Last Name:BATHURST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:BATHURST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2020 BROOK ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-3471
Mailing Address - Country:US
Mailing Address - Phone:254-845-4322
Mailing Address - Fax:
Practice Address - Street 1:3000 HERRING AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3239
Practice Address - Country:US
Practice Address - Phone:254-202-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J6404Medicare PIN