Provider Demographics
NPI:1992704803
Name:IGLESIA, GREGORY COLEMAN (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:COLEMAN
Last Name:IGLESIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78667-1005
Mailing Address - Country:US
Mailing Address - Phone:512-396-8565
Mailing Address - Fax:512-396-8567
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-396-8565
Practice Address - Fax:512-396-8567
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH79912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103672502Medicaid
TX880858ZOtherBCBSTX
TX00TS99OtherBCBSSTX
TX880858ZOtherBCBSTX
TX83R493Medicare ID - Type UnspecifiedMEDICARE