Provider Demographics
NPI:1194750646
Name:INGRAM, GREGORY C (OD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:INGRAM
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 1:111 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3111
Mailing Address - Country:US
Mailing Address - Phone:740-373-2069
Mailing Address - Fax:740-373-2069
Practice Address - Street 1:111 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3111
Practice Address - Country:US
Practice Address - Phone:740-373-2069
Practice Address - Fax:740-373-2069
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0394210Medicaid
OH0523894Medicare PIN
OH0394210Medicaid