Provider Demographics
NPI:1457544181
Name:DEATHERAGE, GREGORY ERIC
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ERIC
Last Name:DEATHERAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GREGORY
Other - Middle Name:ERIC
Other - Last Name:DEATHERAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNAO ABOC
Mailing Address - Street 1:2916 GARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1002
Mailing Address - Country:US
Mailing Address - Phone:940-723-7241
Mailing Address - Fax:
Practice Address - Street 1:2916 GARNETT AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1002
Practice Address - Country:US
Practice Address - Phone:940-723-7241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0860560001Medicare NSC