Provider Demographics
NPI:1154364743
Name:KNOWLES, GARY (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:KNOWLES
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 1:506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1915
Mailing Address - Country:US
Mailing Address - Phone:503-623-9233
Mailing Address - Fax:503-623-9233
Practice Address - Street 1:506 MAIN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1915
Practice Address - Country:US
Practice Address - Phone:503-623-9233
Practice Address - Fax:503-623-9233
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1547T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279018Medicaid
OR0310568863OtherEYE MED
OR022775000OtherBLUE CROSS
OR7072090OtherAETNA
OR93093OtherLIFEWISE
OR002118501001OtherCATERPILLAR
OR93082710497338OtherTRICARE
OR31107OtherUNITED MEDICAL RESOURCES
OR93029OtherPACIFIC SOURCE
ORO000790187OtherMUTUAL OF OMAHA
OR279018Medicaid
OR002118501001OtherCATERPILLAR
ORR0000PHDKBMedicare PIN