Provider Demographics
NPI:1205083094
Name:VANDEGRIFT, GREGORY JAMES
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:VANDEGRIFT
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 1:5686 POCOWILLIS CT
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8299
Mailing Address - Country:US
Mailing Address - Phone:614-855-0191
Mailing Address - Fax:
Practice Address - Street 1:5686 POCOWILLIS CT
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8299
Practice Address - Country:US
Practice Address - Phone:614-855-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist