Provider Demographics
NPI:1831799238
Name:GREESON, JERRY GEORGE (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:GEORGE
Last Name:GREESON
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24526 DREW GAP
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-2284
Mailing Address - Country:US
Mailing Address - Phone:210-365-8316
Mailing Address - Fax:
Practice Address - Street 1:2239 WALKER AVE BLDG 5570
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5632
Practice Address - Country:US
Practice Address - Phone:210-365-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT0646207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty