Provider Demographics
NPI:1700366325
Name:BROWN, GRETTA G (OD)
Entity Type:Individual
Prefix:DR
First Name:GRETTA
Middle Name:G
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 THEATRE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2817
Mailing Address - Country:US
Mailing Address - Phone:814-269-3660
Mailing Address - Fax:814-269-2229
Practice Address - Street 1:410 THEATRE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2817
Practice Address - Country:US
Practice Address - Phone:814-269-3660
Practice Address - Fax:814-269-2229
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035919020001Medicaid