Provider Demographics
NPI:1144375221
Name:STANISLAV, GREGORY VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:VINCENT
Last Name:STANISLAV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:933 E PIERCE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4626
Mailing Address - Country:US
Mailing Address - Phone:712-396-7460
Mailing Address - Fax:712-396-7465
Practice Address - Street 1:933 E PIERCE ST STE 206
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-7460
Practice Address - Fax:712-396-7465
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17498208600000X
IA29675208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
278675Medicare ID - Type Unspecified
E70368Medicare UPIN