Provider Demographics
NPI:1952379687
Name:GREGG, MARK VICTOR (DC, PC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VICTOR
Last Name:GREGG
Suffix:
Gender:M
Credentials:DC, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2303 N 44TH ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-2442
Mailing Address - Country:US
Mailing Address - Phone:602-840-3351
Mailing Address - Fax:602-840-3351
Practice Address - Street 1:2303 N 44TH ST
Practice Address - Street 2:SUITE 15
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2442
Practice Address - Country:US
Practice Address - Phone:602-840-3351
Practice Address - Fax:602-840-3351
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZDC4455Medicare PIN