Provider Demographics
NPI:1205875788
Name:ORTH, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:ORTH
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 1:1770 IOWA AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7401
Mailing Address - Country:US
Mailing Address - Phone:951-786-0801
Mailing Address - Fax:
Practice Address - Street 1:1700 LAKE ALVAMAR DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-9303
Practice Address - Country:US
Practice Address - Phone:785-760-2937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428207174400000X
TXS69102085R0202X
DEC1-00256002085R0202X
KS04-282072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100087980AMedicaid
KS055735Medicare ID - Type Unspecified