Provider Demographics
NPI:1366525909
Name:CROOK, GARY G (O D)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:CROOK
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 BOBBY JONES EXPY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-5255
Mailing Address - Country:US
Mailing Address - Phone:706-860-1171
Mailing Address - Fax:706-860-1841
Practice Address - Street 1:217 BOBBY JONES EXPY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-5255
Practice Address - Country:US
Practice Address - Phone:706-860-1171
Practice Address - Fax:706-860-1841
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52540781004OtherBCBS
SCDAG983Medicaid
GAGA0717OtherEYEMED
SCDPG717Medicaid
GA41ZCFDKMedicare ID - Type Unspecified
SCDPG717Medicaid
GAGA0717OtherEYEMED
GAGRP4752Medicare ID - Type UnspecifiedGROUP NUMBER