Provider Demographics
NPI:1447392709
Name:HUBER, GARY TY (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:TY
Last Name:HUBER
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 1:1444 13TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1639
Mailing Address - Country:US
Mailing Address - Phone:773-802-5829
Mailing Address - Fax:
Practice Address - Street 1:2711 COMMERCE DR NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2262
Practice Address - Country:US
Practice Address - Phone:773-802-5829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2967152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02003Medicare UPIN
K11645Medicare ID - Type Unspecified