Provider Demographics
NPI:1053467142
Name:GAY, RICHARD EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWIN
Last Name:GAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:19173 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48230
Practice Address - Country:US
Practice Address - Phone:313-882-7883
Practice Address - Fax:313-882-5128
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901003248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T96962Medicare UPIN