MEDICARE: MARISSA GREGUREK RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT87342	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86176279	OTHER		REGISTERED DIETITIAN
2	DT87342	OTHER	TX	LICENSED DIETITIAN

General Provider Information

NPI Number	:	1083346134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA GREGUREK RD

Provider Business Mailing Address
First Line	:	4525 GUADALUPE ST APT 207
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-3097
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 GUADALUPE ST APT 207
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-3097
Country	:	US
Telephone Number	:	979-209-9104
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2022
Last Update Date	:	06/28/2022

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Directions to “ MARISSA GREGUREK RD” Practice Location

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