Provider Demographics
NPI:1346809522
Name:SUE, GREGORY JOHN CALVIN (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN CALVIN
Last Name:SUE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 ABERDEEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WHITE SANDS MISSILE RANGE
Mailing Address - State:NM
Mailing Address - Zip Code:88002
Mailing Address - Country:US
Mailing Address - Phone:575-674-3500
Mailing Address - Fax:
Practice Address - Street 1:1363 ABERDEEN AVENUE
Practice Address - Street 2:
Practice Address - City:WHITE SANDS MISSILE RANGE
Practice Address - State:NM
Practice Address - Zip Code:88002
Practice Address - Country:US
Practice Address - Phone:575-674-3505
Practice Address - Fax:915-742-7459
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0065014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program