Provider Demographics
NPI:1679672729
Name:BLY, KREGG S (OD)
Entity Type:Individual
Prefix:DR
First Name:KREGG
Middle Name:S
Last Name:BLY
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 1:5300 HIGHWAY 18 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9411
Mailing Address - Country:US
Mailing Address - Phone:601-922-3233
Mailing Address - Fax:601-922-9225
Practice Address - Street 1:5300 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9411
Practice Address - Country:US
Practice Address - Phone:601-922-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251027OtherNVA
MS42775OtherDAVIS
MS16054OtherSPECTERA
MSMS0598OtherEYEMED/COLE
MS00880136Medicaid
MS26696OtherAVESIS
MSMS0598OtherEYEMED/COLE
MS251027OtherNVA
MS42775OtherDAVIS