Provider Demographics
NPI:1861410730
Name:GREGORY, CHESLEY LELWYNN (MD ,OD)
Entity type:Individual
Prefix:DR
First Name:CHESLEY
Middle Name:LELWYNN
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD ,OD
Other - Prefix:DR
Other - First Name:CHET
Other - Middle Name:LELWYNN
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, OD
Mailing Address - Street 1:9425 HEALTHPLEX DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8154
Mailing Address - Country:US
Mailing Address - Phone:318-683-5171
Mailing Address - Fax:318-683-5182
Practice Address - Street 1:9425 HEALTHPLEX DR STE 101
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8154
Practice Address - Country:US
Practice Address - Phone:318-683-5171
Practice Address - Fax:318-683-5182
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA765-002T152W00000X
LA202699207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No152W00000XEye and Vision Services ProvidersOptometrist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1578240Medicaid
LA1150631Medicaid
LA1578240OtherMEDICAID (TIE BREAKER TAXONOMY 207Q00000X)
LAT19562Medicare UPIN
LA48432DJ57Medicare PIN
LA1578240OtherMEDICAID (TIE BREAKER TAXONOMY 207Q00000X)
LA48432Medicare ID - Type Unspecified