Provider Demographics
NPI:1265548283
Name:GREGG, ROBERT EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:GREGG
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 1:466 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3416
Mailing Address - Country:US
Mailing Address - Phone:419-756-8000
Mailing Address - Fax:419-756-2601
Practice Address - Street 1:1060 CLAREMONT AVE
Practice Address - Street 2:SUITE #5
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3715
Practice Address - Country:US
Practice Address - Phone:419-289-7182
Practice Address - Fax:419-289-0893
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2828/T866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0123315Medicaid
OHGR0157941Medicare ID - Type Unspecified
OH0123315Medicaid