Provider Demographics
NPI:1033816954
Name:GERARD, GORDON CARL
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:CARL
Last Name:GERARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3579 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4008
Mailing Address - Country:US
Mailing Address - Phone:614-409-0695
Mailing Address - Fax:614-409-0697
Practice Address - Street 1:3579 S HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4008
Practice Address - Country:US
Practice Address - Phone:614-409-0695
Practice Address - Fax:614-409-0697
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4134156FX1800X
4134156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician