Provider Demographics
NPI:1124134747
Name:CROSBY, GARY R (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:CROSBY
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 1:820 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2412
Mailing Address - Country:US
Mailing Address - Phone:309-833-4242
Mailing Address - Fax:309-833-3597
Practice Address - Street 1:820 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2412
Practice Address - Country:US
Practice Address - Phone:309-833-4242
Practice Address - Fax:309-833-3597
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006389152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005584004OtherBLUE CROSS BLUE SHIELD
IL046006389Medicaid
IL5012480001Medicare NSC
K27616Medicare PIN