Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 758 | MS |
NPI | 1013096825 |
---|---|
Provider Name | Dr. Gregory D Loose |
First Address | Wiggins, MS 39577-9605 |
Second Address | Wiggins, MS 39577-9605 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2006 |
Last Update Date | 26/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01374059 | (05) | MS |
V12059 | (02) | MS |