Provider Demographics
NPI:1659456663
Name:GREG VANZANT, MD,PA
Entity type:Organization
Organization Name:GREG VANZANT, MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:VANZANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-294-7444
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-0102
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:201 WALLS DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4007
Practice Address - Country:US
Practice Address - Phone:817-641-2551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8476207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX006960101Medicaid
TX006960101OtherAMERIGROUP
TX084919201Medicaid
TX00R82ZOtherBCBSTX
TX084919201OtherAMERIGROUP
TX00C23COtherBCBSTX
TX084919201Medicaid
TX006960101Medicaid