Basic Information
| Provider Information | |||||||||
| NPI: | 1528169208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 W PUTNAM AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597813700 | ||||||||
| FaxNumber: | 5597814131 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 W PUTNAM AVE | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597813700 | ||||||||
| FaxNumber: | 5597814131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208D00000X | G7754 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00G7754 | 05 | CA | MEDICAID |