MEDICARE: GLEN R. GAERTE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT5669	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003855172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN R. GAERTE O.D.

Provider Business Mailing Address
First Line	:	PO BOX 2200
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92373-0722
Country	:	US
Telephone Number	:	909-793-3311
Fax Number	:	909-796-4158

Provider Business Practice Location Address
First Line	:	1300 E COOLEY DR
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-3905
Country	:	US
Telephone Number	:	909-370-4100
Fax Number	:	909-796-4158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/08/2007

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