Provider Demographics
NPI:1205917473
Name:MARKESON, GREG B (OD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:B
Last Name:MARKESON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11146 SWEETWATER PATH
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5293
Mailing Address - Country:US
Mailing Address - Phone:651-436-3499
Mailing Address - Fax:
Practice Address - Street 1:1750 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3919
Practice Address - Country:US
Practice Address - Phone:651-306-0412
Practice Address - Fax:651-306-0414
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020722500Medicaid