Healthcare Provider Details

I. General information

NPI: 1780672287
Provider Name (Legal Business Name): GREGORY NORKUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 EDWINA DR
VIDALIA GA
30474-8963
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-538-9977
  • Fax:
Mailing address:
  • Phone: 912-537-4986
  • Fax: 912-538-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number5216
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number038317
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: