Provider Demographics
NPI:1598761991
Name:LOWE, GREGORY KEITH
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KEITH
Last Name:LOWE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:911 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2115
Practice Address - Country:US
Practice Address - Phone:706-695-4676
Practice Address - Fax:706-695-7364
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582350453OtherTAX ID
GA00787971AMedicaid
GAGAA11212Medicare ID - Type Unspecified
GA582350453OtherTAX ID
GA1182970001Medicare NSC