Provider Demographics
NPI:1295829752
Name:JONES, GREGORY DONALD (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DONALD
Last Name:JONES
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 1:255 SOUTH SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1609
Mailing Address - Country:US
Mailing Address - Phone:651-335-1846
Mailing Address - Fax:651-464-6260
Practice Address - Street 1:WALMART VISION CTR #2274
Practice Address - Street 2:200 KSW 12TH ST
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1609
Practice Address - Country:US
Practice Address - Phone:651-464-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1908152W00000X
WI1876152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB19461046411OtherMEDICAID
MN2202279OtherMEDICA
MN5C403JOOtherBCBS
MN2202278 THRU 2202296OtherMEDICA
MNB19461046411OtherMEDICAID