Provider Demographics
NPI:1861591349
Name:GRESHAM, TRAVIS A III (OD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
Last Name:GRESHAM
Suffix:III
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 1:25225 CHAMBER OF COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7887
Mailing Address - Country:US
Mailing Address - Phone:239-495-2020
Mailing Address - Fax:239-947-2020
Practice Address - Street 1:25225 CHAMBER OF COMMERCE DR
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7887
Practice Address - Country:US
Practice Address - Phone:239-495-2020
Practice Address - Fax:239-947-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2016-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL1224152W00000X
FLOPC1224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL406580311OtherR.R. MEDICARE
FLT84062Medicare UPIN
FL0699780001Medicare NSC
FL19618Medicare PIN