Provider Demographics
NPI:1104918820
Name:GAMMAGE, PAUL D (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:GAMMAGE
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 1:3232 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1439
Mailing Address - Country:US
Mailing Address - Phone:616-669-2530
Mailing Address - Fax:616-669-3646
Practice Address - Street 1:3232 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1439
Practice Address - Country:US
Practice Address - Phone:616-669-2530
Practice Address - Fax:616-669-3646
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900G010150OtherBLUE CROSS BLUE SHIELD
MIMI3318OtherEYEMED
MIP31367FOtherBLUE CARE NETWORK
MI382911868OtherPRIORITY HEALTH
MI2704876Medicaid
MIMI3318OtherEYEMED
MI900G010150OtherBLUE CROSS BLUE SHIELD
MI0883760001Medicare NSC
MIP31367FOtherBLUE CARE NETWORK