Provider Demographics
NPI:1235545435
Name:COLEY, GERALD I
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:COLEY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 MT. VIEW, SUITE F
Mailing Address - Street 2:UNIVERSITY OPTICAL
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3807
Mailing Address - Country:US
Mailing Address - Phone:909-796-8000
Mailing Address - Fax:909-796-8004
Practice Address - Street 1:11175 MT. VIEW AVE.,UNIVERSITY OPTICAL
Practice Address - Street 2:SUITE F
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3807
Practice Address - Country:US
Practice Address - Phone:909-796-8000
Practice Address - Fax:909-796-8004
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD2597156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician