Basic Information
| Provider Information | |||||||||
| NPI: | 1396786398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSIMI | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6330 N CENTER DRIVE | ||||||||
| Address2: | BUILDING 13 SUITE 220 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Practice Location | |||||||||
| Address1: | 6330 N CENTER DRIVE | ||||||||
| Address2: | BUILDING 13 SUITE 220 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 0101056922 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 6606083 | 05 | VA | MEDICAID |