Provider Demographics
NPI:1669551008
Name:JESPERSEN, GREGORY R (DPM)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:JESPERSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-1786
Mailing Address - Country:US
Mailing Address - Phone:425-788-1484
Mailing Address - Fax:425-788-2024
Practice Address - Street 1:19309 218TH PL NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98077-7112
Practice Address - Country:US
Practice Address - Phone:425-788-1484
Practice Address - Fax:425-788-2024
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000415213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA213E00000XMedicaid
WA213E00000XMedicaid
WAG000109016Medicare PIN