Provider Demographics
NPI:1659432185
Name:BRUSH, GARY T (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:T
Last Name:BRUSH
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:PO BOX 890
Mailing Address - Street 2:1801 E 5TH STREET
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960
Mailing Address - Country:US
Mailing Address - Phone:618-524-9323
Mailing Address - Fax:618-524-9324
Practice Address - Street 1:1801 E 5TH STREET
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960
Practice Address - Country:US
Practice Address - Phone:618-524-9323
Practice Address - Fax:618-524-9324
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0413890001OtherDMERC
IL046008374Medicaid
IL0413890001Medicare NSC
ILT98129Medicare UPIN
IL046008374Medicaid