Provider Demographics
NPI:1215346325
Name:GRESS, DAMIAN (MD)
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:GRESS
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 1:65 DROVERS LN
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-8833
Mailing Address - Country:US
Mailing Address - Phone:224-217-1744
Mailing Address - Fax:
Practice Address - Street 1:943 W 14TH PL
Practice Address - Street 2:UNIT 2 B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2287
Practice Address - Country:US
Practice Address - Phone:224-217-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076926208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076926OtherNONE