Provider Demographics
NPI:1184632390
Name:GARY L. ENGLUND,OD, APC
Entity Type:Organization
Organization Name:GARY L. ENGLUND,OD, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-238-1001
Mailing Address - Street 1:1112 VINE ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-5505
Mailing Address - Country:US
Mailing Address - Phone:805-238-1001
Mailing Address - Fax:
Practice Address - Street 1:1112 VINE ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-5505
Practice Address - Country:US
Practice Address - Phone:805-238-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOL 2984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001440Medicaid
CAWY7320AMedicare PIN
CA0312300002Medicare NSC