Provider Demographics
NPI:1801023973
Name:WINE, GREGORY GAGE (MSRD)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:GAGE
Last Name:WINE
Suffix:
Gender:M
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2315 STOCKTON BLVD
Mailing Address - Street 2:STE 0102
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-703-3117
Mailing Address - Fax:916-703-3118
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:STE 0102
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-703-3117
Practice Address - Fax:916-703-3118
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered