Provider Demographics
NPI:1588772156
Name:GILGE, LEROY W (OD)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:W
Last Name:GILGE
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:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-0566
Mailing Address - Country:US
Mailing Address - Phone:503-873-2788
Mailing Address - Fax:
Practice Address - Street 1:114 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-2019
Practice Address - Country:US
Practice Address - Phone:503-873-2788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1160ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR69427Medicaid
OR69427Medicaid
OR0341610001Medicare NSC
ORR0000PGBXNMedicare PIN