Provider Demographics
NPI:1104878982
Name:MASIMORE, GREGORY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:MASIMORE
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 1:730 EXECUTIVE PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-3213
Mailing Address - Country:US
Mailing Address - Phone:317-346-7246
Mailing Address - Fax:317-543-3763
Practice Address - Street 1:730 EXECUTIVE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-3213
Practice Address - Country:US
Practice Address - Phone:317-346-7246
Practice Address - Fax:317-543-3763
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042621A208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000476069OtherSIA ANTHEM
IN200816430Medicaid
IN546430PMedicare ID - Type UnspecifiedSIA
IN200816430Medicaid
INM400029325Medicare PIN
INP00414452Medicare PIN
IN547260CCMedicare PIN