Provider Demographics
NPI:1477626661
Name:GREGORY, MARY LYNN (OD FCOVD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:OD FCOVD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 CEDAR STREET
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8403
Mailing Address - Country:US
Mailing Address - Phone:763-271-2020
Mailing Address - Fax:
Practice Address - Street 1:560 CEDAR STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8403
Practice Address - Country:US
Practice Address - Phone:763-271-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN219J5GROtherBCBS
MN127621OtherU CARE
MN2201727OtherMEDICA
MN2201727OtherSELECT CARE
MNP00236593OtherMEDICARE RAILROAD
MN030242200Medicaid
MNHP29102OtherHEALTH PARTNERS
MN1187490001Medicare NSC
MN2201727OtherSELECT CARE
MNP00236593OtherMEDICARE RAILROAD