Provider Demographics
NPI:1902024961
Name:HARRELSON, GREGORY SHAW (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SHAW
Last Name:HARRELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7040 GADSDEN HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-2680
Mailing Address - Country:US
Mailing Address - Phone:205-655-8833
Mailing Address - Fax:205-655-8836
Practice Address - Street 1:7040 GADSDEN HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-2680
Practice Address - Country:US
Practice Address - Phone:205-655-8833
Practice Address - Fax:205-655-8836
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-452-TA-275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT68928Medicare UPIN