MEDICARE: DR. GREGORY JOHN DUELLMAN D.O.

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	2085R0202X	Diagnostic Radiology Physician	2007-00979	NC
2	2085R0202X	Diagnostic Radiology Physician	34.008149	OH

General Provider Information

NPI Number	:	1417029455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY JOHN DUELLMAN D.O.

Provider Business Mailing Address
First Line	:	336 BURTONWOOD DR
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-4054
Country	:	US
Telephone Number	:	704-867-8021
Fax Number	:	704-864-4606

Provider Business Practice Location Address
First Line	:	14121 LISSADELL CIR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3137
Country	:	US
Telephone Number	:	704-975-9730
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	06/20/2019

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