Provider Demographics
NPI:1275552572
Name:POOLE, RAYMOND GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:GARY
Last Name:POOLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:R. GARY
Other - Middle Name:
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:152 SUMMERLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-7232
Mailing Address - Country:US
Mailing Address - Phone:843-651-6262
Mailing Address - Fax:
Practice Address - Street 1:1115 W FLOYD BAKER BLVD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-1411
Practice Address - Country:US
Practice Address - Phone:864-487-2020
Practice Address - Fax:864-487-3510
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1282152W00000X
PAOEG000142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC29580OtherSPECTRA
SCD12822Medicaid
SCSC9828OtherPTAN
SCD12822Medicaid