Basic Information
| Provider Information | |||||||||
| NPI: | 1598761991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOWE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | KEITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 N 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307052115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066954676 | ||||||||
| FaxNumber: | 7066957364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 02/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001580 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 582350453 | 01 | GA | TAX ID | OTHER | 00787971A | 05 | GA | MEDICAID |