Provider Demographics
NPI:1215980040
Name:WEISBRUCH, GREGORY JOHN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:WEISBRUCH
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 1:3206 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5143
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:903-663-7394
Practice Address - Street 1:3500 GASTON AVENUE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-826-8822
Practice Address - Fax:214-826-9792
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG84962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139986729Medicaid
TX139986727Medicaid
TX139986726Medicaid
TX8A9013Medicare PIN
TXP00034806Medicare PIN
TX8021B9Medicare PIN
TX139986726Medicaid
TX139986729Medicaid
TX8C8523Medicare PIN
TX8C2507Medicare PIN