Provider Demographics
NPI:1366460727
Name:REEVES, GREGORY (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:REEVES
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:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-0489
Mailing Address - Country:US
Mailing Address - Phone:901-465-3955
Mailing Address - Fax:901-465-6797
Practice Address - Street 1:105 E MARKET ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-1407
Practice Address - Country:US
Practice Address - Phone:901-465-3955
Practice Address - Fax:901-465-6797
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6369990001Medicare NSC