Provider Demographics
NPI:1861516007
Name:WALDROP, GARY DANIEL (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DANIEL
Last Name:WALDROP
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 SHASTA DAM BLVD
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9413
Mailing Address - Country:US
Mailing Address - Phone:530-275-8581
Mailing Address - Fax:530-275-8596
Practice Address - Street 1:4601 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9413
Practice Address - Country:US
Practice Address - Phone:530-275-8581
Practice Address - Fax:530-275-8596
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141463156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9419OtherMEDICAL EYE SERVICES
CADX067260FMedicaid
CACA4661OtherEYE MED PROVIDER NUMBER
CACA4661OtherEYE MED PROVIDER NUMBER