Provider Demographics
NPI:1508898925
Name:GERCHAK, DAVID J (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:GERCHAK
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 1:1001 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7017
Mailing Address - Country:US
Mailing Address - Phone:918-456-5511
Mailing Address - Fax:918-458-2310
Practice Address - Street 1:1001 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-7017
Practice Address - Country:US
Practice Address - Phone:918-456-5511
Practice Address - Fax:918-458-2310
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2452152W00000X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02365Medicare UPIN