Provider Demographics
NPI:1548274657
Name:ST. CLAIR, GARY HOUSTON (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:HOUSTON
Last Name:ST. CLAIR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:20838 TIMBERLAKE RD
Mailing Address - Street 2:STE A
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-7241
Mailing Address - Country:US
Mailing Address - Phone:434-239-2800
Mailing Address - Fax:434-237-7037
Practice Address - Street 1:20838A TIMBERLAKE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7241
Practice Address - Country:US
Practice Address - Phone:434-239-2800
Practice Address - Fax:434-237-7037
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009204555Medicaid
VAT87772Medicare UPIN
VA410000427Medicare PIN