Provider Demographics
NPI:1346233780
Name:GOBERVILLE, GARY E (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:GOBERVILLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:E
Other - Last Name:GOBERVILLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:9804 S MILITARY TRL STE E7
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-3220
Practice Address - Country:US
Practice Address - Phone:561-738-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2575152WP0200X, 152WS0006X, 152WV0400X
FLOPC2575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078957700Medicaid
FL078957700Medicaid
FL20377Medicare PIN