Healthcare Provider Details

I. General information

NPI: 1154328011
Provider Name (Legal Business Name): GREGORY GENE EYRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 JEAN AVE
SOUTH LAKE TAHOE CA
96150-3412
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 530-543-5691
  • Fax: 531-542-2872
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA83380
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10616
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: