Provider Demographics
NPI:1205831427
Name:RENIER, GARY L (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:RENIER
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 1:101 10TH ST N
Mailing Address - Street 2:STE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4600
Mailing Address - Country:US
Mailing Address - Phone:701-239-9771
Mailing Address - Fax:701-293-0944
Practice Address - Street 1:101 10TH ST N
Practice Address - Street 2:STE 120
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4600
Practice Address - Country:US
Practice Address - Phone:701-239-9771
Practice Address - Fax:701-293-0944
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND339152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11351OtherBLUE CROSS/BLUE SHIELD
ND60417Medicaid
MN2C934REOtherBLUE CROSS/ BLUE SHIELD
ND2227152OtherMEDICA
ND2227152OtherMEDICA
ND11351OtherBLUE CROSS/BLUE SHIELD