Provider Demographics
NPI:1073515482
Name:RECK, GARY L (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:RECK
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 1:506 ATHENA DR
Mailing Address - Street 2:
Mailing Address - City:DELMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15626-1005
Mailing Address - Country:US
Mailing Address - Phone:724-468-6869
Mailing Address - Fax:724-468-6207
Practice Address - Street 1:506 ATHENA DR
Practice Address - Street 2:
Practice Address - City:DELMONT
Practice Address - State:PA
Practice Address - Zip Code:15626-1005
Practice Address - Country:US
Practice Address - Phone:724-468-6869
Practice Address - Fax:724-468-6207
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE6001104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015200410002Medicaid
MD356208500Medicaid
MD356208500Medicaid
PA406508ZNTXMedicare PIN
655354Medicare ID - Type Unspecified
PA0729800001Medicare NSC
PA406508ZNTYMedicare PIN
MD406508ZNTXMedicare PIN
MD506989ZVDDMedicare PIN