Provider Demographics
NPI:1023464476
Name:MEDVED, GREGORY SCOTT
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:MEDVED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 N 1225 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8912
Mailing Address - Country:US
Mailing Address - Phone:801-645-5628
Mailing Address - Fax:
Practice Address - Street 1:1874 N 1225 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8912
Practice Address - Country:US
Practice Address - Phone:801-645-5628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program