Provider Demographics
NPI:1689718314
Name:HEACOCK, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:HEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2002 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3282
Mailing Address - Country:US
Mailing Address - Phone:410-266-3900
Mailing Address - Fax:410-266-9245
Practice Address - Street 1:2002 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 230
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3282
Practice Address - Country:US
Practice Address - Phone:410-266-3900
Practice Address - Fax:410-266-9245
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0055675207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD607361100Medicaid
F47439Medicare UPIN
MD607361100Medicaid