Provider Demographics
NPI:1790744084
Name:REICHHARDT, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:REICHHARDT
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 1:1517 16TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4574
Mailing Address - Country:US
Mailing Address - Phone:970-392-2490
Mailing Address - Fax:970-392-2177
Practice Address - Street 1:1517 16TH AVENUE CT
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4574
Practice Address - Country:US
Practice Address - Phone:970-392-2490
Practice Address - Fax:970-392-2177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31969208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01319698Medicaid
COF39360Medicare UPIN
CO01319698Medicaid