Provider Demographics
NPI:1760613368
Name:GREGORY L. KANE OD PA
Entity Type:Organization
Organization Name:GREGORY L. KANE OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:386-328-8387
Mailing Address - Street 1:514 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4148
Mailing Address - Country:US
Mailing Address - Phone:386-328-8387
Mailing Address - Fax:386-325-0644
Practice Address - Street 1:514 S PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4148
Practice Address - Country:US
Practice Address - Phone:386-328-8387
Practice Address - Fax:386-325-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP-0001874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078282300Medicaid