Provider Demographics
NPI:1790715522
Name:MASSOUD, GREGORY (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MASSOUD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 S DOBSON RD
Practice Address - Street 2:CHANDLER REGIONAL MEDICAL CENTER
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-1797
Practice Address - Country:US
Practice Address - Phone:480-728-3753
Practice Address - Fax:480-728-3305
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4023207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH70172Medicare UPIN
AZ81824Medicare ID - Type Unspecified