MEDICARE: MICHAEL RAY GERDTS LTD

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	6836T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6836T	OTHER	TX	TEXAS OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1669606349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL RAY GERDTS LTD

Provider Business Mailing Address
First Line	:	1508 RESEARCH FOREST DR
Second Line	:	SUITE 200
City	:	SHENANDOAH
State	:	TX
Zip	:	77381-4374
Country	:	US
Telephone Number	:	281-466-1700
Fax Number	:	281-466-1704

Provider Business Practice Location Address
First Line	:	1508 RESEARCH FOREST DR
Second Line	:	SUITE 200
City	:	SHENANDOAH
State	:	TX
Zip	:	77381-4374
Country	:	US
Telephone Number	:	281-466-1700
Fax Number	:	281-466-1704

Authorized Official
Title or Position	:	DOCTOR OF OPTOMETRY
Name	:	MICHAEL R. GERDTS
Credential	:	OD
Telephone Number	:	281-466-1700

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	05/08/2009

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