Provider Demographics
NPI:1265433478
Name:UPCHURCH, GARY WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:WALTER
Last Name:UPCHURCH
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0306
Mailing Address - Country:US
Mailing Address - Phone:606-492-2211
Mailing Address - Fax:606-676-0873
Practice Address - Street 1:127 FOOTHILLS AVE STE 3
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1037
Practice Address - Country:US
Practice Address - Phone:606-387-5612
Practice Address - Fax:606-387-6602
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD2197152W00000X
KY929DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01047034OtherAMERIGROUP
TN4599126Medicaid
KY4627OtherAVESIS/MEDICAID
3068022OtherBCBSTN/BLUECARE/TENNCARE
KY7100209970Medicaid
KY77009298Medicaid
KY410003588OtherRAILROAD MEDICARE
TN4599126Medicaid
KY77009298Medicaid
3068022OtherBCBSTN/BLUECARE/TENNCARE