MEDICARE: DR. DARRYL DODD GREGERSON DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3878	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46813	OTHER	IA	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669587077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARRYL DODD GREGERSON DC

Provider Business Mailing Address
First Line	:	2518 E KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-6712
Country	:	US
Telephone Number	:	918-286-2729
Fax Number	:	918-286-0651

Provider Business Practice Location Address
First Line	:	2518 E KENOSHA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74014-6712
Country	:	US
Telephone Number	:	918-286-2729
Fax Number	:	918-286-0651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/22/2008

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