Provider Demographics
NPI:1770767600
Name:GREGORY, GEORGE W (MD, FACC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 CROWN RIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-8936
Mailing Address - Country:US
Mailing Address - Phone:830-515-5744
Mailing Address - Fax:830-515-5776
Practice Address - Street 1:2105 CROWN RIDGE DR.
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-8936
Practice Address - Country:US
Practice Address - Phone:830-515-5744
Practice Address - Fax:830-515-5776
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41184208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG41184OtherMEDICAL LICENSE
PAGR164327OtherMEDICARE PROVIDER #
PAD71582Medicare UPIN