Provider Demographics
NPI:1679635429
Name:GEMOULES, GREG (OD)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:GEMOULES
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 1:712 S. DENTON TAP RD.
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-462-7311
Mailing Address - Fax:972-462-7312
Practice Address - Street 1:712 S. DENTON TAP RD.
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019
Practice Address - Country:US
Practice Address - Phone:972-462-7311
Practice Address - Fax:972-462-7312
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX751987544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E83JMedicare UPIN