Provider Demographics
NPI:1316936214
Name:WHEELER, GARY H (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:H
Last Name:WHEELER
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 1:309 GENESSEE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7107
Mailing Address - Country:US
Mailing Address - Phone:541-779-2095
Mailing Address - Fax:541-779-0667
Practice Address - Street 1:309 GENESSEE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7107
Practice Address - Country:US
Practice Address - Phone:541-779-2095
Practice Address - Fax:541-779-0667
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1095T152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0443320001OtherMEDICARE SUPPLY PIN
OKA003OtherTRICARE
OR0443320001Medicare NSC
OKA003OtherTRICARE
OR103826Medicare ID - Type Unspecified