Provider Demographics
NPI:1093477184
Name:GREGG, BILLY JACK
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:JACK
Last Name:GREGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BILLY
Other - Middle Name:JACK
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BILLY JACK GREGG
Mailing Address - Street 1:7321 EDENBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5617
Mailing Address - Country:US
Mailing Address - Phone:405-779-1525
Mailing Address - Fax:
Practice Address - Street 1:23899 STATE HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-6964
Practice Address - Country:US
Practice Address - Phone:405-779-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program