Provider Demographics
NPI:1679782841
Name:PUTALIK, GREGORY C (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:C
Last Name:PUTALIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:643 E LAKE ST
Mailing Address - Street 2:# 4
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-1239
Mailing Address - Country:US
Mailing Address - Phone:231-526-5041
Mailing Address - Fax:231-242-4700
Practice Address - Street 1:643 E LAKE ST
Practice Address - Street 2:#4
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-1239
Practice Address - Country:US
Practice Address - Phone:231-242-4734
Practice Address - Fax:231-242-4700
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301050511207Q00000X
MI50511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4081535Medicaid
MIM75310002Medicare PIN
MIB48955Medicare UPIN