Provider Demographics
NPI:1326144346
Name:GRIDLEY, BARRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:L
Last Name:GRIDLEY
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419-1505
Practice Address - Country:US
Practice Address - Phone:937-298-0550
Practice Address - Fax:937-298-5404
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3121/T1009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0248057Medicaid
0408691Medicare ID - Type Unspecified