Provider Demographics
NPI:1669435533
Name:JENNINGS, GORDON W (OD PC)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:W
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2326
Mailing Address - Country:US
Mailing Address - Phone:276-228-2771
Mailing Address - Fax:276-228-9097
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2326
Practice Address - Country:US
Practice Address - Phone:276-228-2771
Practice Address - Fax:276-228-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009234268Medicaid
VA541900685OtherTAX ID
VA1669435533OtherNPI
VA079556OtherANTHEM BCBS
VAVA05215911OtherUMWA
VAVA05215911OtherUMWA
VA410001086Medicare PIN
VA1669435533OtherNPI