Provider Demographics
NPI:1770663635
Name:PHILLIPS, GREGORY (DPM)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PHILLIPS
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 1:337 S WHITE ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2916
Mailing Address - Country:US
Mailing Address - Phone:919-554-0711
Mailing Address - Fax:919-554-1185
Practice Address - Street 1:337 S WHITE ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2916
Practice Address - Country:US
Practice Address - Phone:919-554-0711
Practice Address - Fax:919-554-1185
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC442213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08099OtherBLUECROSS BLUESHIELD
PAT86774Medicare UPIN