Provider Demographics
NPI:1821080144
Name:TIRDEL, GREGORY B (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
Last Name:TIRDEL
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 1:10956 DONNER PASS RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4861
Mailing Address - Country:US
Mailing Address - Phone:530-582-6400
Mailing Address - Fax:530-582-6991
Practice Address - Street 1:10956 DONNER PASS RD
Practice Address - Street 2:SUITE 260
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4861
Practice Address - Country:US
Practice Address - Phone:530-582-6400
Practice Address - Fax:530-582-6991
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69661207R00000X, 207RC0200X
CAG696610207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1827433Medicaid
CAZZZ21753ZOtherMEDICARE GROUP
CA00G696610Medicare UPIN
CA1827433Medicaid