Provider Demographics
NPI:1114934247
Name:KAUTZ, GREGORY G (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:G
Last Name:KAUTZ
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 1:660 CAPITOL ST. N.E.
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-364-0512
Mailing Address - Fax:503-588-7108
Practice Address - Street 1:660 CAPITOL ST. N.E.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-364-0512
Practice Address - Fax:503-588-7108
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1545ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228429Medicaid
ORT67774Medicare UPIN
OR228429Medicaid