Provider Demographics
NPI:1063578169
Name:BRANNON, GREGORY RAY (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RAY
Last Name:BRANNON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-1944
Mailing Address - Country:US
Mailing Address - Phone:304-269-4456
Mailing Address - Fax:304-269-4468
Practice Address - Street 1:165 MAIN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-1944
Practice Address - Country:US
Practice Address - Phone:304-269-4456
Practice Address - Fax:304-269-4468
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV667OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150025000Medicaid
WVMB0091227OtherDEA NUMBER
WV0150025000Medicaid
WVT32538Medicare UPIN