Provider Demographics
NPI:1760636005
Name:GRESHAM OPTICAL, INC
Entity Type:Organization
Organization Name:GRESHAM OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROPHY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-667-2424
Mailing Address - Street 1:2150 NE DIVISION ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5813
Mailing Address - Country:US
Mailing Address - Phone:503-667-2424
Mailing Address - Fax:503-492-3236
Practice Address - Street 1:2150 NE DIVISION ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5813
Practice Address - Country:US
Practice Address - Phone:503-667-2424
Practice Address - Fax:503-492-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001060Medicaid
ORU-19383Medicare UPIN
ORR0000PHGGPMedicare Oscar/Certification