Provider Demographics
NPI:1396890372
Name:GAYLORD, GREGG MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:MICHAEL
Last Name:GAYLORD
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 1:805 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4241
Mailing Address - Country:US
Mailing Address - Phone:414-988-6773
Mailing Address - Fax:414-301-7253
Practice Address - Street 1:805 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4241
Practice Address - Country:US
Practice Address - Phone:414-988-6773
Practice Address - Fax:414-301-7253
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI384402085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32301700Medicaid
WI32301700Medicaid