Provider Demographics
NPI:1841239647
Name:CONNER, GREGORY LAURENT (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LAURENT
Last Name:CONNER
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 1:2191 MEMORIAL DR
Mailing Address - Street 2:APTARTMENT G95
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4797
Mailing Address - Country:US
Mailing Address - Phone:931-553-7855
Mailing Address - Fax:
Practice Address - Street 1:2191 MEMORIAL DR
Practice Address - Street 2:APTARTMENT G95
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4797
Practice Address - Country:US
Practice Address - Phone:931-553-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02777207P00000X
TN2028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00255239OtherRAILROAD MEDICARE
KY64062813Medicaid
KY000000290234OtherBLUE CROSS BLUE SHIELD
KYP00255239OtherRAILROAD MEDICARE
KY0954392Medicare ID - Type Unspecified