Provider Demographics
NPI:1396740262
Name:PABALIS, GARY R (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:PABALIS
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 1:11972 W GAMEKEEPER DR
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2802
Mailing Address - Country:US
Mailing Address - Phone:208-562-6285
Mailing Address - Fax:208-377-9455
Practice Address - Street 1:5680 W GAGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1326
Practice Address - Country:US
Practice Address - Phone:208-377-3937
Practice Address - Fax:208-377-9455
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100002152W00000X
AZ295152W00000X
UT114212-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806834700Medicaid
ID1594247Medicare ID - Type Unspecified
IDT89176Medicare UPIN