Provider Demographics
NPI:1578618989
Name:HERRON, GAIL C JR
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:C
Last Name:HERRON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SOUTHEAST BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3481
Mailing Address - Country:US
Mailing Address - Phone:330-332-8801
Mailing Address - Fax:330-332-5447
Practice Address - Street 1:2400 SOUTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3481
Practice Address - Country:US
Practice Address - Phone:330-332-8801
Practice Address - Fax:330-332-5447
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH2889152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339824Medicaid
OHHE0376802Medicare ID - Type UnspecifiedOPTOMETRIST
OH0339824Medicaid
OHT46264Medicare UPIN