Provider Demographics
NPI:1285688192
Name:PETRICK GATCHELL, THERESA LYNN (OD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:PETRICK GATCHELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S KOELLER ROAD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902
Mailing Address - Country:US
Mailing Address - Phone:920-426-5730
Mailing Address - Fax:920-426-1708
Practice Address - Street 1:1300 S KOELLER ROAD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902
Practice Address - Country:US
Practice Address - Phone:920-426-5730
Practice Address - Fax:920-426-1708
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2857-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38615900Medicaid
WIU63449Medicare UPIN