Provider Demographics
NPI:1841361797
Name:CUSACK, GREGORY JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:CUSACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2801 YGNACIO VALLEY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598
Mailing Address - Country:US
Mailing Address - Phone:925-945-0555
Mailing Address - Fax:925-945-1873
Practice Address - Street 1:2801 YGNACIO VALLEY RD
Practice Address - Street 2:SUITE B
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-945-0555
Practice Address - Fax:925-945-1873
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18025ZMedicare ID - Type Unspecified