Provider Demographics
NPI:1922171123
Name:BACA, GREGORY K (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:K
Last Name:BACA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:112 GRAND CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:464 CENTRAL AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3350
Practice Address - Country:US
Practice Address - Phone:505-795-5217
Practice Address - Fax:505-747-9696
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2008-05532084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry