Provider Demographics
NPI:1427153071
Name:GOVRIK, GREGORY LASZLO (DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LASZLO
Last Name:GOVRIK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23505 SMITHTOWN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-4541
Mailing Address - Country:US
Mailing Address - Phone:952-470-8555
Mailing Address - Fax:
Practice Address - Street 1:23505 SMITHTOWN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-4541
Practice Address - Country:US
Practice Address - Phone:952-470-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650001942Medicare PIN