Provider Demographics
NPI:1023132982
Name:COGDILL, GARY BRENT (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRENT
Last Name:COGDILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30024
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0024
Mailing Address - Country:US
Mailing Address - Phone:336-765-3169
Mailing Address - Fax:336-659-0998
Practice Address - Street 1:3320 SILAS CREEK PKWY
Practice Address - Street 2:SUITE 280
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3031
Practice Address - Country:US
Practice Address - Phone:336-765-3159
Practice Address - Fax:336-659-0998
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC37527Medicare UPIN
NC2468235Medicare ID - Type Unspecified