Provider Demographics
NPI:1710199724
Name:THAERA, GREG (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:THAERA
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 1:12221 N MOPAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-901-4011
Mailing Address - Fax:512-901-3911
Practice Address - Street 1:12221 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2401
Practice Address - Country:US
Practice Address - Phone:512-901-4011
Practice Address - Fax:512-901-3911
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP57432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01330570OtherRRMC PTAN
TX323968301Medicaid
TX295405YPV2Medicare PIN