Basic Information
| Provider Information | |||||||||
| NPI: | 1548234255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WUEBBOLT | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | EDGAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WUEBBOLT | ||||||||
| OtherFirstName: | GORDON | ||||||||
| OtherMiddleName: | EDGAR | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1100X | MD052930L | PA | N | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic | 156FX1100X | 219642-1 | NY | N | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic | 207W00000X | 219642-1 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0200X | 219642-1 | NY | N | 207WX0200X | MD052930L | PA | N | 207W00000X | MD052930L | PA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 001464588 | 05 | PA | MEDICAID | 02155728 | 05 | NY | MEDICAID |