Healthcare Provider Details

I. General information

NPI: 1568997559
Provider Name (Legal Business Name): GREGORY ABDULLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GREGORY DEENRAUSAN ABDULLAH R.T(R)CT

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 E MISTLETOE AVE
SAN ANTONIO TX
78212-3407
US

IV. Provider business mailing address

PO BOX 778
GANADO AZ
86505-0778
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-1100
  • Fax:
Mailing address:
  • Phone: 520-604-7560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number17913
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number31426
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: