Provider Demographics
NPI:1073896825
Name:GATES, KHRYS (OD)
Entity Type:Individual
Prefix:DR
First Name:KHRYS
Middle Name:
Last Name:GATES
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 4000
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6003
Mailing Address - Fax:928-737-6080
Practice Address - Street 1:HWY 264 MILE POST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042-4000
Practice Address - Country:US
Practice Address - Phone:928-737-6003
Practice Address - Fax:928-737-6080
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid