Provider Demographics
NPI:1265456321
Name:GREGG, ERIC MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MATTHEW
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 1:1266 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-2802
Mailing Address - Country:US
Mailing Address - Phone:610-543-1219
Mailing Address - Fax:610-543-1524
Practice Address - Street 1:1266 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:SECANE
Practice Address - State:PA
Practice Address - Zip Code:19018-2802
Practice Address - Country:US
Practice Address - Phone:610-543-1219
Practice Address - Fax:610-543-1524
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-001809152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00356676Medicare PIN
PA104151KNNMedicare PIN
PAV10423Medicare UPIN
PA0241340001Medicare NSC