Healthcare Provider Details

I. General information

NPI: 1134197718
Provider Name (Legal Business Name): MICHAEL E GREGORY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 RODEO RD SUITE B13
SANTA FE NM
87507-6503
US

IV. Provider business mailing address

2801 RODEO RD SUITE B13
SANTA FE NM
87507-6503
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-6097
  • Fax:
Mailing address:
  • Phone: 505-474-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2003-0666
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: