MEDICARE: GREGORY ABDULLAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247100000X	Radiologic Technologist	17913	AZ
2	2471C3401X	Computed Tomography Radiologic Technologist	31426	AZ

General Provider Information

NPI Number	:	1568997559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY ABDULLAH

Provider Business Mailing Address
First Line	:	PO BOX 778
Second Line	:
City	:	GANADO
State	:	AZ
Zip	:	86505-0778
Country	:	US
Telephone Number	:	520-604-7560
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 E MISTLETOE AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-3407
Country	:	US
Telephone Number	:	210-223-1100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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