Provider Demographics
NPI:1629068259
Name:GENTRY, LARS A (OD)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:A
Last Name:GENTRY
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 1:1207 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1388
Mailing Address - Country:US
Mailing Address - Phone:618-384-3411
Mailing Address - Fax:618-382-7226
Practice Address - Street 1:1207 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1388
Practice Address - Country:US
Practice Address - Phone:618-384-3411
Practice Address - Fax:618-382-7226
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL931571Medicare ID - Type Unspecified
U03054Medicare UPIN