Provider Demographics
NPI:1669439899
Name:GREGORY, MYRA ANN (DO, LLC)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:ANN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DO, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 DUNCAN REGIONAL LOOP
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1564
Mailing Address - Country:US
Mailing Address - Phone:580-252-1373
Mailing Address - Fax:
Practice Address - Street 1:1324 N HARVILLE RD
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1514
Practice Address - Country:US
Practice Address - Phone:580-252-1373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100120120AMedicaid
OK100120120FMedicaid
OK245533501Medicare ID - Type Unspecified
OK100120120AMedicaid
OKOK100377Medicare PIN
OKF28652Medicare UPIN