Provider Demographics
NPI:1942769104
Name:GREGG, ANDREW MARK (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARK
Last Name:GREGG
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10945 LE CONTE AVE STE 2114
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6949
Mailing Address - Country:US
Mailing Address - Phone:424-440-3824
Mailing Address - Fax:
Practice Address - Street 1:10945 LE CONTE AVE STE 2114
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6949
Practice Address - Country:US
Practice Address - Phone:424-440-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA177654390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty