Provider Demographics
NPI:1154438737
Name:SERVETAS, GREGORY T (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:SERVETAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 MAIN STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-374-0404
Mailing Address - Fax:203-372-4167
Practice Address - Street 1:3180 MAIN STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-374-0404
Practice Address - Fax:203-372-4167
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT031632207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001316323Medicaid
CT001316323Medicaid
160002181Medicare ID - Type Unspecified