Provider Demographics
NPI:1952422958
Name:CHILDRESS, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 WESTGATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2932
Mailing Address - Country:US
Mailing Address - Phone:336-768-4140
Mailing Address - Fax:336-768-4487
Practice Address - Street 1:1364 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2932
Practice Address - Country:US
Practice Address - Phone:336-768-4140
Practice Address - Fax:336-768-4487
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC683156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4254540001Medicare NSC