Provider Demographics
NPI:1952488314
Name:KEITH, GREGORY LEE (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:KEITH
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 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-283-7300
Mailing Address - Fax:423-283-4729
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-283-7300
Practice Address - Fax:423-283-4729
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1679152W00000X
VA2046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U60486Medicare UPIN
3940173Medicare ID - Type Unspecified