Provider Demographics
NPI: | 1942368840 |
---|---|
Name: | WEST, GREGORY V (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | GREGORY |
Middle Name: | V |
Last Name: | WEST |
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: | 960 E. WALNUT LAWN STREET |
Mailing Address - Street 2: | SUITE 201 |
Mailing Address - City: | SPRINGFIELD |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 65807 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 417-269-4450 |
Mailing Address - Fax: | 417-269-8333 |
Practice Address - Street 1: | 960 E. WALNUT LAWN STREET |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | MO |
Practice Address - Zip Code: | 65807 |
Practice Address - Country: | US |
Practice Address - Phone: | 417-269-4450 |
Practice Address - Fax: | 417-269-8333 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-04 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 116239 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
431560263067 | Other | TRICARE | |
110248694 | Other | RAILROAD MEDICARE | |
MO | 209988336 | Medicaid | |
110248694 | Other | RAILROAD MEDICARE | |
MO | G70145 | Medicare UPIN | |
MO | 209988336 | Medicaid |