Provider Demographics
NPI:1912978867
Name:GRECO, ANTHONY DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DANIEL
Last Name:GRECO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2260
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-2260
Mailing Address - Country:US
Mailing Address - Phone:928-242-2422
Mailing Address - Fax:928-532-8474
Practice Address - Street 1:5658 WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5189
Practice Address - Country:US
Practice Address - Phone:928-532-5463
Practice Address - Fax:928-532-8474
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22688208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0789570OtherBLUE CROSS BLUE SHIELD AZ
AZ179318Medicaid
E92029Medicare UPIN
E92029Medicare UPIN