Provider Demographics
NPI:1366521726
Name:FAGERT, GREGORY J (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:FAGERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-0355
Mailing Address - Country:US
Mailing Address - Phone:330-482-4124
Mailing Address - Fax:330-482-4124
Practice Address - Street 1:14 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-1347
Practice Address - Country:US
Practice Address - Phone:330-482-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4099/T050152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH976574Medicaid
OHFA0693192Medicare PIN
OH410019644Medicare PIN
OH976574Medicaid