Provider Demographics
NPI:1659534063
Name:BURGOYNE, GREGORY BRENT (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:BRENT
Last Name:BURGOYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 209
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5169
Mailing Address - Country:US
Mailing Address - Phone:386-231-3520
Mailing Address - Fax:
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 209
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0075015208600000X
FLME138235208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery