Individual
DR. JACK LEON GREGSTON
Active
Individual
DR. JACK LEON GREGSTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
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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