Provider Demographics
NPI:1922097153
Name:HAVRANEK, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:HAVRANEK
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 1:1315 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-4213
Mailing Address - Country:US
Mailing Address - Phone:724-843-1870
Mailing Address - Fax:724-843-7275
Practice Address - Street 1:1315 6TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4213
Practice Address - Country:US
Practice Address - Phone:724-843-1870
Practice Address - Fax:724-843-7275
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000663152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009693170001Medicaid
PA410001500OtherMEDICARE RAILROAD
PA0009693170001Medicaid
PA0400040001Medicare NSC
PA121778Medicare PIN