Provider Demographics
NPI:1528057056
Name:BORSTAD, GREGORY CLARK
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:CLARK
Last Name:BORSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6442
Mailing Address - Country:US
Mailing Address - Phone:910-762-1182
Mailing Address - Fax:
Practice Address - Street 1:1710 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6442
Practice Address - Country:US
Practice Address - Phone:910-762-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00896208M00000X, 207RR0500X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR147970Medicare PIN
OR500609171Medicaid
OR00834434OtherMEDICARE RAILROAD