Provider Demographics
NPI:1699715698
Name:FARLEY, GARY L (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:FARLEY
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 1:3731 BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834
Mailing Address - Country:US
Mailing Address - Phone:804-526-3676
Mailing Address - Fax:804-520-5781
Practice Address - Street 1:3731 BLVD
Practice Address - Street 2:STE A
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834
Practice Address - Country:US
Practice Address - Phone:804-526-3676
Practice Address - Fax:804-520-5781
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA014917OtherANTHEM
VA410008652AOtherMEDICARE RR
VA9206931Medicaid
VA410008652AOtherMEDICARE RR
VA410000126Medicare ID - Type Unspecified