Provider Demographics
NPI:1215047352
Name:GARY GREGASAVITCH, DPM, PC
Entity type:Organization
Organization Name:GARY GREGASAVITCH, DPM, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:GREGASAVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-858-3211
Mailing Address - Street 1:44055 RIVERSIDE PKWY
Mailing Address - Street 2:SUITE 228
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5179
Mailing Address - Country:US
Mailing Address - Phone:703-858-3211
Mailing Address - Fax:703-858-3212
Practice Address - Street 1:44055 RIVERSIDE PKWY
Practice Address - Street 2:SUITE 228
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-5179
Practice Address - Country:US
Practice Address - Phone:703-858-3211
Practice Address - Fax:703-858-3212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300881261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1215047352OtherNPI- CLINIC
1316992381OtherNPI
VA010294148Medicaid
U95761Medicare UPIN
VA5746050001Medicare NSC