Provider Demographics
NPI:1700888559
Name:GRESH, JOHN PROSPERO (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PROSPERO
Last Name:GRESH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 SW 34TH CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-6621
Mailing Address - Country:US
Mailing Address - Phone:352-861-0100
Mailing Address - Fax:352-861-1119
Practice Address - Street 1:3301 SW 34TH CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-6621
Practice Address - Country:US
Practice Address - Phone:352-861-0100
Practice Address - Fax:352-861-1119
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0049373174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253616100Medicaid
FLBCBSOther08641
FLE22569Medicare UPIN
FL253616100Medicaid