Provider Demographics
NPI:1619940947
Name:MOYER, GREGORY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:MOYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:970 S SILVER LAKE ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3802
Mailing Address - Country:US
Mailing Address - Phone:262-569-7100
Mailing Address - Fax:262-567-6295
Practice Address - Street 1:970 S SILVER LAKE ST
Practice Address - Street 2:STE. 102
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3802
Practice Address - Country:US
Practice Address - Phone:262-569-7100
Practice Address - Fax:262-567-6295
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI35710208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG48742Medicare UPIN