Provider Demographics
NPI:1790877975
Name:VINES, GARY L (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:VINES
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 1:333 E HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5724
Mailing Address - Country:US
Mailing Address - Phone:865-982-6110
Mailing Address - Fax:865-977-7243
Practice Address - Street 1:333 E HARPER AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5724
Practice Address - Country:US
Practice Address - Phone:865-982-6110
Practice Address - Fax:865-977-7243
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0DT1895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5820190001Medicare NSC
3943757Medicare ID - Type Unspecified
U71622Medicare UPIN