Provider Demographics
NPI:1134170905
Name:PHILLIPS, JERRY LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:PHILLIPS
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 1:2423 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-1481
Mailing Address - Country:US
Mailing Address - Phone:541-729-4778
Mailing Address - Fax:541-484-7674
Practice Address - Street 1:2864 WILLAMETTE ST
Practice Address - Street 2:SUITE 600
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3297
Practice Address - Country:US
Practice Address - Phone:541-689-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR332H00000X
OR2681 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295849Medicaid
OR1134170905Medicare PIN
ORU80272Medicare UPIN