Provider Demographics
NPI:1093746620
Name:MYERS, GARY BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRUCE
Last Name:MYERS
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 1:1140 MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-2168
Mailing Address - Country:US
Mailing Address - Phone:760-789-1191
Mailing Address - Fax:760-789-1216
Practice Address - Street 1:1140 MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2168
Practice Address - Country:US
Practice Address - Phone:760-789-1191
Practice Address - Fax:760-789-1216
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7998T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP7998OtherBLUE SHIELD
CASD0079980Medicaid
CAT70244Medicare UPIN
CAOP7998Medicare PIN