Provider Demographics
NPI:1376585919
Name:KESTERSON, GREGG HD (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:HD
Last Name:KESTERSON
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 1:7731 CHEROKEE SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-9030
Mailing Address - Country:US
Mailing Address - Phone:865-470-2468
Mailing Address - Fax:
Practice Address - Street 1:105 BROYLES DR
Practice Address - Street 2:SUITE B
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2542
Practice Address - Country:US
Practice Address - Phone:423-722-4000
Practice Address - Fax:423-722-4004
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17126207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110098564OtherRR MEDICARE PIN
TN3019399Medicaid
TN110098564OtherRR MEDICARE PIN
TN3019394Medicare ID - Type UnspecifiedLEGACY PIN
TN110098564OtherRR MEDICARE PIN