Provider Demographics
NPI:1013932052
Name:MACDONELL, GREGORY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:MACDONELL
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 1:718 UNIVERSITY AVE
Mailing Address - Street 2:#211
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032
Mailing Address - Country:US
Mailing Address - Phone:408-354-2114
Mailing Address - Fax:
Practice Address - Street 1:15195 NATIONAL AVE
Practice Address - Street 2:#100
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032
Practice Address - Country:US
Practice Address - Phone:408-356-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59930207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G599300Medicaid
CA00G599300Medicaid
A90026Medicare UPIN