Provider Demographics
NPI:1598989246
Name:GATES, JEFFERY EUGENE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:EUGENE
Last Name:GATES
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 1:5 OAK LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1385
Mailing Address - Country:US
Mailing Address - Phone:304-842-6525
Mailing Address - Fax:
Practice Address - Street 1:552 EMILY DR
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-5508
Practice Address - Country:US
Practice Address - Phone:304-623-2892
Practice Address - Fax:304-622-2809
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV-903OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149812000Medicaid
WV0149812001Medicaid
WV0149812000Medicaid
WVU33029Medicare UPIN
WV0149812001Medicaid