Provider Demographics
NPI:1538218201
Name:GREGG, JOLENE GAYLE (OD)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:GAYLE
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 1:1219 50TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5878
Mailing Address - Country:US
Mailing Address - Phone:941-374-9974
Mailing Address - Fax:
Practice Address - Street 1:17700 MURDOCK CIR
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1054
Practice Address - Country:US
Practice Address - Phone:941-374-9974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2357152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU30173Medicare UPIN
FL19183Medicare ID - Type Unspecified