1679744148 NPI number — WAYNE L GERIG OD

Table of content: (NPI 1679744148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679744148 NPI number — WAYNE L GERIG OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE L GERIG OD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
20/20 EYECARE PROFESSIONALS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679744148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10225 SW HALL BLVD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-244-1004
Provider Business Mailing Address Fax Number:
503-244-1006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10225 SW HALL BLVD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-8855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-244-1004
Provider Business Practice Location Address Fax Number:
503-244-1006
Provider Enumeration Date:
03/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GERIG
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-244-1004

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1478AT , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 283135 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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