Provider Demographics
NPI:1295890689
Name:HAWK, GARY D (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:HAWK
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 1:318 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1615
Mailing Address - Country:US
Mailing Address - Phone:814-746-5902
Mailing Address - Fax:
Practice Address - Street 1:1825 DOWNS DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-7303
Practice Address - Country:US
Practice Address - Phone:814-864-8617
Practice Address - Fax:814-860-3286
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE004898P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014504500001Medicaid
PA1014504500001Medicaid