Provider Demographics
NPI:1679744148
Name:WAYNE L GERIG OD
Entity type:Organization
Organization Name:WAYNE L GERIG OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GERIG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-244-1004
Mailing Address - Street 1:10225 SW HALL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8855
Mailing Address - Country:US
Mailing Address - Phone:503-244-1004
Mailing Address - Fax:503-244-1006
Practice Address - Street 1:10225 SW HALL BLVD
Practice Address - Street 2:STE 101
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8855
Practice Address - Country:US
Practice Address - Phone:503-244-1004
Practice Address - Fax:503-244-1006
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE L GERIG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-12
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1478AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR283135Medicaid
ORT67641Medicare UPIN
OR0692360001Medicare NSC
OR283135Medicaid