Healthcare Provider Details

I. General information

NPI: 1326163890
Provider Name (Legal Business Name): GREGORY GANZER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 CHAPLINE ST
WHEELING WV
26003-3855
US

IV. Provider business mailing address

2101 CHAPLINE ST
WHEELING WV
26003-3855
US

V. Phone/Fax

Practice location:
  • Phone: 304-233-3240
  • Fax: 304-233-4176
Mailing address:
  • Phone: 304-233-3240
  • Fax: 304-233-4176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1159
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number34005620
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS006564L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: