Provider Demographics
NPI:1659355139
Name:GREGERSON, DOUGLAS M (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:GREGERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0 S. 630 PRESTON CR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-845-0862
Mailing Address - Fax:630-578-1018
Practice Address - Street 1:0 S. 630 PRESTON CR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-845-0862
Practice Address - Fax:630-578-1018
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL625810Medicare ID - Type Unspecified