Provider Demographics
NPI:1376523654
Name:TATUM, GARY E (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:TATUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:922 N WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-3129
Mailing Address - Country:US
Mailing Address - Phone:409-384-5192
Mailing Address - Fax:409-384-5615
Practice Address - Street 1:922 N WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-3129
Practice Address - Country:US
Practice Address - Phone:409-384-5192
Practice Address - Fax:409-384-5615
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1847T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist