Provider Demographics
NPI:1255383584
Name:TACKMAN, GARY E (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:TACKMAN
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 1:2530 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1390
Mailing Address - Country:US
Mailing Address - Phone:906-786-2295
Mailing Address - Fax:906-786-2816
Practice Address - Street 1:2530 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1390
Practice Address - Country:US
Practice Address - Phone:906-786-2295
Practice Address - Fax:906-786-2816
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP06330001Medicare ID - Type Unspecified
U59266Medicare UPIN