Healthcare Provider Details

I. General information

NPI: 1043248453
Provider Name (Legal Business Name): JOHN CONSTANTINE GRETES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7552 HOSPITAL DR STE 302
GLOUCESTER VA
23061-4178
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-693-9062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101025205
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: