Healthcare Provider Details

I. General information

NPI: 1528169208
Provider Name (Legal Business Name): JACK GREGORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 W PUTNAM AVE SUITE 2A
PORTERVILLE CA
93257-3257
US

IV. Provider business mailing address

590 W PUTNAM AVE SUITE 2A
PORTERVILLE CA
93257-3257
US

V. Phone/Fax

Practice location:
  • Phone: 559-781-3700
  • Fax: 559-781-4131
Mailing address:
  • Phone: 559-781-3700
  • Fax: 559-781-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG7754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: