Provider Demographics
NPI:1720097157
Name:BANNETT, GREGG ALLEN (DO)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:ALLEN
Last Name:BANNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:620 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1795
Mailing Address - Country:US
Mailing Address - Phone:856-853-5554
Mailing Address - Fax:856-853-5650
Practice Address - Street 1:620 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1795
Practice Address - Country:US
Practice Address - Phone:856-853-5554
Practice Address - Fax:856-853-5650
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04846500174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ613700M7DMedicare UPIN