Provider Demographics
NPI:1063428407
Name:PHILLIPS, GERALD D (OD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:D
Last Name:PHILLIPS
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 1:3030 E 29TH STREET
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2740
Mailing Address - Country:US
Mailing Address - Phone:979-731-8446
Mailing Address - Fax:979-731-8275
Practice Address - Street 1:3030 E 29TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2757
Practice Address - Country:US
Practice Address - Phone:979-731-8446
Practice Address - Fax:979-731-8275
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02145T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16110OtherSPECTERA
TX80323EOtherBLUE CROSS BLUE SHIELD
TX3750OtherBLOCK VISION
TX54812OtherDAVIS VISION
TX6271OtherAVESIS
TXTX2145OtherEYEMED
TX16258OtherSCOTT & WHITE
TX112311903Medicaid
TX59496OtherSAFEGUARD
TX16258OtherSCOTT & WHITE
TX16110OtherSPECTERA
TX112311903Medicaid