Provider Demographics
NPI:1982623658
Name:FOSSUM, GREGORY T (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:T
Last Name:FOSSUM
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 1:400 RANDY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-4014
Mailing Address - Country:US
Mailing Address - Phone:215-429-8358
Mailing Address - Fax:
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2118
Practice Address - Country:US
Practice Address - Phone:786-596-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046162L207VE0102X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME121321OtherFLORIDA STATE MEDICAL LICENSE
PA001272293Medicaid
NJ7608209Medicaid
FLME121321OtherFLORIDA STATE MEDICAL LICENSE