Provider Demographics
NPI:1992729206
Name:DEVRIES, GERRIT H (OD)
Entity type:Individual
Prefix:DR
First Name:GERRIT
Middle Name:H
Last Name:DEVRIES
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 849
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0849
Mailing Address - Country:US
Mailing Address - Phone:219-987-3673
Mailing Address - Fax:219-987-3905
Practice Address - Street 1:609 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9545
Practice Address - Country:US
Practice Address - Phone:219-987-3673
Practice Address - Fax:219-987-3905
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001809B152W00000X, 152WC0802X, 152WX0102X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100142770AMedicaid
IN100142770AMedicaid
INT34742Medicare UPIN