Provider Demographics
NPI:1336473107
Name:GENGENBACH, ERIC ROSS (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ROSS
Last Name:GENGENBACH
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 1:115 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:NE
Mailing Address - Zip Code:69140-3107
Mailing Address - Country:US
Mailing Address - Phone:308-352-4424
Mailing Address - Fax:
Practice Address - Street 1:115 W 3RD ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:NE
Practice Address - Zip Code:69140-3107
Practice Address - Country:US
Practice Address - Phone:308-352-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEH12509768OtherDRIVER'S LICENSE NUMBER