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General NPI Number Information
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NPI Number | 1538218201
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Entity Type | Individual
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Provider Name | JOLENE GAYLE GREGG O.D.
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Gender | Female
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 01/02/2014
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Provider Practice Location Address
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Address Line | 17700 MURDOCK CIR
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-1054
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Country | US
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Telephone | 941-374-9974
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Fax |
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Provider Business Mailing Address
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Address Line | 1219 50TH STREET CT E
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City | BRADENTON
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State | FL
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Zip | 34208-5878
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Country | US
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Telephone | 941-374-9974
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC2357
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License Number State | FL
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