Provider Demographics
NPI:1184766560
Name:STAGNONE, GREGORY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:STAGNONE
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 1:6190 LYNDON B JOHNSON FWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6344
Mailing Address - Country:US
Mailing Address - Phone:972-661-5077
Mailing Address - Fax:972-661-5755
Practice Address - Street 1:6190 LYNDON B JOHNSON FWY
Practice Address - Street 2:SUITE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6344
Practice Address - Country:US
Practice Address - Phone:972-661-5077
Practice Address - Fax:972-661-5755
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE89816Medicare UPIN