Basic Information
| Provider Information | |||||||||
| NPI: | 1215980040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISBRUCH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3206 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036634800 | ||||||||
| FaxNumber: | 9036637394 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 GASTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148268822 | ||||||||
| FaxNumber: | 2148269792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G8496 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 139986729 | 05 | TX | MEDICAID | 139986727 | 05 | TX | MEDICAID | 139986726 | 05 | TX | MEDICAID |