Provider Demographics
NPI:1881666030
Name:RADISH, GARY EARLE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EARLE
Last Name:RADISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2699 TOWNSEND CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6487
Mailing Address - Country:US
Mailing Address - Phone:931-647-8417
Mailing Address - Fax:931-648-4435
Practice Address - Street 1:2699 TOWNSEND CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6487
Practice Address - Country:US
Practice Address - Phone:931-647-8417
Practice Address - Fax:931-648-4435
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599833Medicaid
TNQ009062Medicaid
TN3599833Medicaid
TNQ009062Medicaid
TN0618580001Medicare NSC
U01188Medicare UPIN