Provider Demographics
NPI:1093776205
Name:GERLACH, BRIAN T (OD, FAAO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:GERLACH
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 GRAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822
Mailing Address - Country:US
Mailing Address - Phone:419-586-3151
Mailing Address - Fax:419-586-1059
Practice Address - Street 1:1025 GRAND LAKE RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822
Practice Address - Country:US
Practice Address - Phone:419-586-3151
Practice Address - Fax:419-586-1059
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5038T1915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHL2228397Medicaid
U77523Medicare UPIN
GE0892872Medicare ID - Type Unspecified