Provider Demographics
NPI:1881703049
Name:GREGG, SARAH J (OD)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:J
Last Name:GREGG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 S ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4069
Mailing Address - Country:US
Mailing Address - Phone:815-229-0500
Mailing Address - Fax:815-229-5005
Practice Address - Street 1:1393 S ALPINE RD
Practice Address - Street 2:FAMILY OPTICAL CENTRE INC
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4069
Practice Address - Country:US
Practice Address - Phone:815-229-0500
Practice Address - Fax:815-229-5005
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0792460001Medicare NSC
ILK31469Medicare PIN