Provider Demographics
NPI:1942365515
Name:PROFFITT, GREGORY (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PROFFITT
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 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:1800 GALLERIA BLVD STE 1330
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-1691
Practice Address - Country:US
Practice Address - Phone:615-771-7382
Practice Address - Fax:615-771-7295
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD2200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943876Medicaid
TNU84693Medicare UPIN
TN3943876Medicare ID - Type UnspecifiedOD PIN