Provider Demographics
NPI:1952399313
Name:GREBENNIKOV, VLADIMIR ALEXANDROVICH (MD)
Entity Type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:ALEXANDROVICH
Last Name:GREBENNIKOV
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 1:870 N COIT RD
Mailing Address - Street 2:SUITE 2660
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5420
Mailing Address - Country:US
Mailing Address - Phone:972-235-2459
Mailing Address - Fax:972-235-9435
Practice Address - Street 1:870 N COIT RD
Practice Address - Street 2:SUITE 2660
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5420
Practice Address - Country:US
Practice Address - Phone:972-235-2459
Practice Address - Fax:972-235-9435
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK9291OtherLICENSE
TX1504755-01Medicaid
G93241Medicare UPIN
TX00549MMedicare PIN