Basic Information
| Provider Information | |||||||||
| NPI: | 1942365515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROFFITT | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11103 WEST AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 GALLERIA BLVD STE 1330 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370671691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157717382 | ||||||||
| FaxNumber: | 6157717295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | OD2200 | TN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3943876 | 05 | TN | MEDICAID |