Healthcare Provider Details

I. General information

NPI: 1528057056
Provider Name (Legal Business Name): GREGORY CLARK BORSTAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 S 17TH ST
WILMINGTON NC
28401-6442
US

IV. Provider business mailing address

1710 S 17TH ST
WILMINGTON NC
28401-6442
US

V. Phone/Fax

Practice location:
  • Phone: 910-762-1182
  • Fax:
Mailing address:
  • Phone: 910-762-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2014-00896
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2014-00896
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: