Basic Information
| Provider Information | |||||||||
| NPI: | 1427127133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P,O, BOX 1337 | ||||||||
| Address2: | |||||||||
| City: | CALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873051337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057268740 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E. NIZHONI BLVD. | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057268740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD036355E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.