Provider Demographics
NPI:1235192071
Name:GREGG, KENNETH ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:GREGG
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 1:1201 N BRIGHTLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4229
Mailing Address - Country:US
Mailing Address - Phone:919-934-8152
Mailing Address - Fax:919-934-8154
Practice Address - Street 1:1201 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4229
Practice Address - Country:US
Practice Address - Phone:919-934-8152
Practice Address - Fax:919-934-8154
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09345OtherBCBS PROV #
NCP00777283OtherRR MCARE
NC7909345Medicaid
NC246453SMedicare PIN
NC246453JMedicare PIN
NC7909345Medicaid
NC246453CMedicare PIN
NC246453HMedicare PIN
NC246453KMedicare PIN
NC246453FMedicare PIN
NC246453EMedicare PIN
NC09345OtherBCBS PROV #
NC246453GMedicare PIN