Provider Demographics
NPI:1184605982
Name:GREGORY, STEPHEN R (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:GREGORY
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:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0798
Mailing Address - Country:US
Mailing Address - Phone:812-254-1276
Mailing Address - Fax:812-254-4099
Practice Address - Street 1:400 E NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4114
Practice Address - Country:US
Practice Address - Phone:812-254-1276
Practice Address - Fax:812-254-4099
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100364950AMedicaid
IN410048819Medicare PIN
T86627Medicare UPIN
IN161810BMedicare PIN