Provider Demographics
NPI:1659391506
Name:WARDA, GREGORY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ROBERT
Last Name:WARDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2304 KOSSUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3240
Mailing Address - Country:US
Mailing Address - Phone:765-446-9600
Mailing Address - Fax:928-783-4257
Practice Address - Street 1:2304 KOSSUTH ST
Practice Address - Street 2:BILLING OFFICE
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3240
Practice Address - Country:US
Practice Address - Phone:765-446-9600
Practice Address - Fax:928-783-4257
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ274662080N0001X
CAC507242080N0001X
CO338792080N0001X
IN01064039A2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300010988Medicaid