Provider Demographics
NPI:1528054467
Name:GREGG, LAWRENCE J (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
Last Name:GREGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 52588
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74152-0588
Mailing Address - Country:US
Mailing Address - Phone:918-749-2261
Mailing Address - Fax:918-749-8712
Practice Address - Street 1:2121 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1409
Practice Address - Country:US
Practice Address - Phone:918-749-2261
Practice Address - Fax:918-749-8712
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-05-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK9455207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
730776171002OtherBLUE CROSS BLUE SHIELD
OK100116590AMedicaid
876735OtherAETNA HMO
4053536OtherAETNA PPO
OK9455OtherMEDICAL LICENSE NUMBER
070004141OtherRAILROAD MEDICARE
4053536OtherAETNA PPO
OK9455OtherMEDICAL LICENSE NUMBER