Provider Demographics
NPI:1760920367
Name:TESTAMARCK, GREGORY (LSA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:TESTAMARCK
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 BETHANY LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77039-5715
Mailing Address - Country:US
Mailing Address - Phone:832-526-1849
Mailing Address - Fax:
Practice Address - Street 1:1 SUGAR CREEK CENTER BLVD STE 618
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3540
Practice Address - Country:US
Practice Address - Phone:832-655-4141
Practice Address - Fax:713-457-5188
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00468246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00721OtherTEXAS MEDICAL BOARD
TX8QF483OtherBCBS - UNIVERSAL SURGICAL PARTNERS
TX8PX957OtherBCBS- US MSO
TX8QA718OtherBCBS - BLUE STAR SURGICAL
TX8QC669OtherBCBS - XCITE SURGICAL ASSISTANTS
TX8QC851OtherBCBS - UNIVERSAL SURGICAL ASSISTANTS