Provider Demographics
NPI:1932264520
Name:USDAN, GREGORY (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:USDAN
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 1:857 MOUNT MORIAH RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5704
Mailing Address - Country:US
Mailing Address - Phone:901-767-7080
Mailing Address - Fax:901-767-2020
Practice Address - Street 1:6150 POPLAR AVE STE 115
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4744
Practice Address - Country:US
Practice Address - Phone:901-682-3937
Practice Address - Fax:901-683-6172
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU52411Medicare UPIN
TN3599402Medicare PIN