Provider Demographics
NPI:1891807053
Name:CARL, GREGORY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:CARL
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 1:1200 N 14TH AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301
Mailing Address - Country:US
Mailing Address - Phone:509-545-4800
Mailing Address - Fax:509-545-4861
Practice Address - Street 1:1200 N 14TH AVE
Practice Address - Street 2:STE 220
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301
Practice Address - Country:US
Practice Address - Phone:509-545-4800
Practice Address - Fax:509-545-4861
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022219207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1000660Medicaid
WA1000660Medicaid