Provider Demographics
NPI:1184690117
Name:GRIFFITH, GREGORY A (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:GRIFFITH
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 1:424 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2572
Mailing Address - Country:US
Mailing Address - Phone:814-724-7630
Mailing Address - Fax:814-724-8402
Practice Address - Street 1:424 NORTH ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2572
Practice Address - Country:US
Practice Address - Phone:814-724-7630
Practice Address - Fax:814-724-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR426712OtherBLUE CROSS
PA426712Medicare ID - Type Unspecified
T30365Medicare UPIN