Provider Demographics
NPI:1821283730
Name:MICHAEL R. GERDTS, OD, PA
Entity Type:Organization
Organization Name:MICHAEL R. GERDTS, OD, PA
Other - Org Name:VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:O.D.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GERDTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-466-1888
Mailing Address - Street 1:1108 WOODLANDS MALL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380
Mailing Address - Country:US
Mailing Address - Phone:281-362-1888
Mailing Address - Fax:281-362-9555
Practice Address - Street 1:1108 WOODLANDS MALL
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-362-1888
Practice Address - Fax:281-362-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6836T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX IDENTIFICATION NUMBER