Basic Information
| Provider Information | |||||||||
| NPI: | 1891712592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WLODARSKI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 289 OLMSTED BLVD STE 7 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283749023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102952900 | ||||||||
| FaxNumber: | 9102952935 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 DAGGETT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412748400 | ||||||||
| FaxNumber: | 5412748405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD192071 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 95-01458 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500762160 | 05 | OR | MEDICAID | 88721 | 01 | NC | BCBS | OTHER | 8988721 | 05 | NC | MEDICAID |