Provider Demographics
NPI:1881692671
Name:STONESTREET, GREGORY C (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:STONESTREET
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 1:5480 BIG TYLER RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1116
Mailing Address - Country:US
Mailing Address - Phone:304-776-2409
Mailing Address - Fax:304-776-2023
Practice Address - Street 1:5480 BIG TYLER RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1116
Practice Address - Country:US
Practice Address - Phone:304-776-2409
Practice Address - Fax:304-776-2023
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057324000Medicaid
WVA72649Medicare UPIN
WV0057324000Medicaid