Provider Demographics
NPI:1265566012
Name:GREGORY L. NEDURIAN, M.D., P.A.
Entity type:Organization
Organization Name:GREGORY L. NEDURIAN, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEDURIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-687-0550
Mailing Address - Street 1:521 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4504
Mailing Address - Country:US
Mailing Address - Phone:863-687-0550
Mailing Address - Fax:863-682-7700
Practice Address - Street 1:521 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4504
Practice Address - Country:US
Practice Address - Phone:863-687-0550
Practice Address - Fax:863-682-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0090819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270400500Medicaid
FLP00279741OtherRAILROAD MEDICARE
FLP00279741OtherRAILROAD MEDICARE
FLB41836Medicare UPIN