Provider Demographics
NPI:1427057348
Name:AMELUNG, GREG JACK (DPM)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:JACK
Last Name:AMELUNG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:809 W HARWOOD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-6233
Mailing Address - Country:US
Mailing Address - Phone:817-424-3668
Mailing Address - Fax:817-442-8637
Practice Address - Street 1:1940 E HIGHWAY 114 STE 150
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6526
Practice Address - Country:US
Practice Address - Phone:817-503-0009
Practice Address - Fax:817-503-8909
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1859213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0013MSOtherBCBS GROUP
TX1376738971OtherGROUP NPI
TX1427057348OtherINDIVIDUAL NPI
TX1427057348OtherINDIVIDUAL NPI
TX812659559OtherTIN
TX90-0170193OtherTIN