Provider Demographics
NPI:1245202951
Name:KANE, GREGORY L (OD PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:KANE
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:514 S PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4148
Practice Address - Country:US
Practice Address - Phone:386-328-2387
Practice Address - Fax:386-325-0644
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP-0001874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19176OtherBC BS FL
FL078282300Medicaid
FL19176Medicare ID - Type Unspecified
FL078282300Medicaid
FL19176OtherBC BS FL