Individual
DR. JACK LEON GREGSTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1235 E CHEROKEE ST, SPRINGFIELD, MO 65804-2203
(417) 820-2500
(417) 820-8155
Mailing address
PO BOX 2580, SPRINGFIELD, MO 65801-2580
(417) 829-4620
(417) 829-4316
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
104377
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
134038001
—
AR
01
—
173098
MO BLUE SHIELD
MO
05
—
206769218
—
MO
01
—
81773
AR BLUE SHIELD
AR
01
—
C94989
UPIN
—
Enumeration date
02/05/2007
Last updated
04/27/2009
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