Provider Demographics
NPI:1104829563
Name:SEXTRO, GREGORY S (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:SEXTRO
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 1:620 N DIERS AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4984
Mailing Address - Country:US
Mailing Address - Phone:308-384-5400
Mailing Address - Fax:308-384-5201
Practice Address - Street 1:620 N DIERS AVE
Practice Address - Street 2:STE. 200
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4984
Practice Address - Country:US
Practice Address - Phone:308-384-5400
Practice Address - Fax:308-384-5201
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE21854207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06189OtherBC/BS
NE06189OtherBC/BS
NE278497Medicare PIN