Provider Demographics
NPI:1245422310
Name:GILBREATH & PARK OPTOMETRY INC
Entity Type:Organization
Organization Name:GILBREATH & PARK OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILBREATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-462-7040
Mailing Address - Street 1:102 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4316
Mailing Address - Country:US
Mailing Address - Phone:707-462-7040
Mailing Address - Fax:
Practice Address - Street 1:102 SCOTT ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4316
Practice Address - Country:US
Practice Address - Phone:707-462-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7782T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000510Medicaid
CAGSD000510Medicaid
ZZZ32575ZMedicare PIN