Provider Demographics
NPI:1710939889
Name:OETTING, GREGORY MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARTIN
Last Name:OETTING
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:PO BOX 204630
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30917-4630
Mailing Address - Country:US
Mailing Address - Phone:706-722-6957
Mailing Address - Fax:706-722-7454
Practice Address - Street 1:840 STEVENS CREEK ROAD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:706-722-6957
Practice Address - Fax:706-722-7454
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038575207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA447924301AMedicaid
GA000608814EMedicaid
SCG38575Medicaid
GA14BDHLNMedicare PIN
GA447924301AMedicaid