=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932318052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERY E. GATES, OD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 552 EMILY DR
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301-5508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-623-2892
-----------------------------------------------------
Fax | 304-622-2809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 552 EMILY DR
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301-5508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-623-2892
-----------------------------------------------------
Fax | 304-622-2809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFERY EUGENE GATES
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 304-623-2892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | WV 909-OD
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------