Basic Information
| Provider Information | |||||||||
| NPI: | 1851358683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOMER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 N CENTRAL EXPY | ||||||||
| Address2: | STE 185 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750802754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039338270 | ||||||||
| FaxNumber: | 9724373369 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 TOUR 18 DR | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750226449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039338270 | ||||||||
| FaxNumber: | 9724373369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | J8584 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 152869701 | 05 | TX | MEDICAID |