Provider Demographics
NPI:1114011913
Name:GAZAWAY, JOHN A (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:GAZAWAY
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:P.O. BOX 1185
Mailing Address - Street 2:
Mailing Address - City:LAURIE
Mailing Address - State:MO
Mailing Address - Zip Code:65038
Mailing Address - Country:US
Mailing Address - Phone:573-374-5222
Mailing Address - Fax:573-374-7351
Practice Address - Street 1:138 S. MAIN
Practice Address - Street 2:SUITE C
Practice Address - City:LAURIE
Practice Address - State:MO
Practice Address - Zip Code:65038
Practice Address - Country:US
Practice Address - Phone:573-374-5222
Practice Address - Fax:573-374-7351
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1520T152W00000X
MO2009002132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0057075Medicaid
IA05707OtherBLUE SHIELD
IA05707OtherBLUE SHIELD
IA0057075Medicaid
05707Medicare PIN
156750002Medicare PIN