Provider Demographics
NPI:1790771210
Name:GREGORY, IAN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:DAVID
Last Name:GREGORY
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 1:221 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:JBSA RANDOLPH
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:
Practice Address - City:JBSA RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:201-652-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020030164A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine