Basic Information
| Provider Information | |||||||||
| NPI: | 1285621664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | REEVES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G2379 | TX | Y | Other Service Providers | Specialist | 174400000X | R3021 | AR | N | Other Service Providers | Specialist | 174400000X | L#014100 | LA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | AG1777816 | 01 | DEA NUMBER | OTHER | L#014100 | 01 | LA | LOUISIANA MEDICAL LICENSE | OTHER | 40048923 | 01 | TX | TEXAS CONTROLLED SUB. LIC | OTHER | G2379 | 01 | TX | TX STATE MEDICAL LICENSE | OTHER | 114062601 | 05 | TX | MEDICAID | R-3021 | 01 | AR | ARKANSAS MEDICAL LICENSE | OTHER | 103414001 | 05 | AR | MEDICAID | 19284 | 01 | OK | OKLAHOMA MEDICAL LICENSE | OTHER |