Provider Demographics
NPI:1053622449
Name:DODELL, GREGORY BRENT (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BRENT
Last Name:DODELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:115 CENTRAL PARK WEST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10023-4198
Mailing Address - Country:US
Mailing Address - Phone:212-877-2100
Mailing Address - Fax:212-873-9311
Practice Address - Street 1:115 CENTRAL PARK WEST
Practice Address - Street 2:SUITE 14
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10023-4198
Practice Address - Country:US
Practice Address - Phone:212-877-2100
Practice Address - Fax:212-873-9311
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY257597-1207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1053622449OtherNPI
NY04229067Medicaid