Healthcare Provider Details

I. General information

NPI: 1639118656
Provider Name (Legal Business Name): GREGORY T VANLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE SUITE 105
LONG BEACH CA
90813
US

IV. Provider business mailing address

1045 ATLANTIC AVE SUITE 105
LONG BEACH CA
90813-3408
US

V. Phone/Fax

Practice location:
  • Phone: 562-491-9167
  • Fax: 562-491-7969
Mailing address:
  • Phone: 562-491-9167
  • Fax: 562-491-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA32565
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA32565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: