Provider Demographics
NPI:1538386800
Name:ROGUE VALLEY OPTOMETRIC CLINIC PC
Entity type:Organization
Organization Name:ROGUE VALLEY OPTOMETRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETORY
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:H
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-779-2095
Mailing Address - Street 1:309 GENESSEE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 GENESSEE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7107
Practice Address - Country:US
Practice Address - Phone:541-779-2095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1095T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0443320001Medicare NSC
OR103825Medicare ID - Type Unspecified
ORT68257Medicare UPIN