Provider Demographics
NPI:1649479163
Name:WACASEY, GREGORY KYLE (O D)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:KYLE
Last Name:WACASEY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W LOOP 281
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4442
Mailing Address - Country:US
Mailing Address - Phone:903-663-1550
Mailing Address - Fax:
Practice Address - Street 1:307 W LOOP 281
Practice Address - Street 2:SUITE 2B
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4442
Practice Address - Country:US
Practice Address - Phone:903-663-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7108T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist