Provider Demographics
NPI:1699738583
Name:BOURDAKOS, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BOURDAKOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARIOS
Other - Middle Name:GREGORY
Other - Last Name:BOURDAKOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6000 W CREEK RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2139
Mailing Address - Country:US
Mailing Address - Phone:800-223-2273
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:800-223-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064702B207RC0200X
OH35064702207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2181571Medicaid
OHE38643Medicare UPIN
OHBO7345391Medicare PIN