Provider Demographics
NPI:1457323651
Name:WHITE, GARY B (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:B
Last Name:WHITE
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 1:211 S BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2902
Mailing Address - Country:US
Mailing Address - Phone:815-672-8915
Mailing Address - Fax:815-672-8915
Practice Address - Street 1:211 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2902
Practice Address - Country:US
Practice Address - Phone:815-672-8915
Practice Address - Fax:815-672-8915
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006585Medicaid
IL046006585Medicaid
ILT35337Medicare UPIN
IL0300180001Medicare NSC