Provider Demographics
NPI:1962533570
Name:SCHULZ, GARY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:SCHULZ
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 1:13638 SW BENCHVIEW PL
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1734
Mailing Address - Country:US
Mailing Address - Phone:503-590-2408
Mailing Address - Fax:
Practice Address - Street 1:1265 JANTZEN BEACH CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-7852
Practice Address - Country:US
Practice Address - Phone:503-289-7331
Practice Address - Fax:503-289-0854
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1727T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR078928OtherOMAP NUMBER
ORU-47978Medicare UPIN
OR078928OtherOMAP NUMBER