Provider Demographics
NPI:1013096825
Name:LOOSE, GREGORY D (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:LOOSE
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 1:1113 CENTRAL AVE E
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-9605
Mailing Address - Country:US
Mailing Address - Phone:601-928-3914
Mailing Address - Fax:601-928-2207
Practice Address - Street 1:1113 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-9605
Practice Address - Country:US
Practice Address - Phone:601-928-3914
Practice Address - Fax:601-928-2207
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01374059Medicaid
MS410000299Medicare PIN
MSV12059Medicare UPIN
MS5855760001Medicare NSC