Provider Demographics
NPI:1437346459
Name:GEM OPTICAL, LLC
Entity Type:Organization
Organization Name:GEM OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:301-918-0095
Mailing Address - Street 1:6603 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2908
Mailing Address - Country:US
Mailing Address - Phone:301-918-0095
Mailing Address - Fax:301-918-0097
Practice Address - Street 1:6603 RIVERDALE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2908
Practice Address - Country:US
Practice Address - Phone:301-918-0095
Practice Address - Fax:301-918-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG02835Medicare PIN