Healthcare Provider Details

I. General information

NPI: 1477888568
Provider Name (Legal Business Name): GINA MARIE HEDBERG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA MARIE SILVERS O.D.

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 09/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 GREENWOOD ST
JUNCTION CITY OR
97448-1627
US

IV. Provider business mailing address

1236 MERLOT AVE
EUGENE OR
97404-4525
US

V. Phone/Fax

Practice location:
  • Phone: 541-998-6454
  • Fax:
Mailing address:
  • Phone: 320-224-0610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number831
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3404ATI
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: