Provider Demographics
NPI:1174664205
Name:CAGLE, GREGORY L (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:CAGLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 MALLOW WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2955
Mailing Address - Country:US
Mailing Address - Phone:813-685-0590
Mailing Address - Fax:
Practice Address - Street 1:1016 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4572
Practice Address - Country:US
Practice Address - Phone:813-681-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1625152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T85253Medicare UPIN
19545ZMedicare ID - Type Unspecified
FL5170290001Medicare NSC