Healthcare Provider Details

I. General information

NPI: 1790747665
Provider Name (Legal Business Name): GREGORY P MINDOCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 11/27/2023
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8906 M 89
RICHLAND MI
49083
US

IV. Provider business mailing address

5943 STADIUM DR STE 1
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7130
  • Fax: 269-286-7131
Mailing address:
  • Phone: 269-552-2836
  • Fax: 269-552-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: