Provider Demographics
NPI:1700865961
Name:LE CREN, GILBERT
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:
Last Name:LE CREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-0106
Mailing Address - Country:US
Mailing Address - Phone:541-265-9458
Mailing Address - Fax:541-265-6586
Practice Address - Street 1:111 SE DOUGLAS ST
Practice Address - Street 2:STE D
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4499
Practice Address - Country:US
Practice Address - Phone:541-265-9458
Practice Address - Fax:541-265-6586
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-15
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3015ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276456Medicaid
ORR101407Medicare PIN
U46493Medicare UPIN
1210900001Medicare NSC