Provider Demographics
NPI:1730100876
Name:GENDVILAS, TONY (OD)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:GENDVILAS
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 629
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-0629
Mailing Address - Country:US
Mailing Address - Phone:503-631-8331
Mailing Address - Fax:503-212-9775
Practice Address - Street 1:9499 SW WASHINGTON SQUARE RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4448
Practice Address - Country:US
Practice Address - Phone:503-968-5249
Practice Address - Fax:503-968-9237
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1689T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU05988Medicare UPIN
OR100678Medicare PIN