Provider Demographics
NPI:1033277629
Name:NELSON, GARY H (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:H
Last Name:NELSON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 FAIRMOUNT AVE.
Mailing Address - Street 2:STE 11
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2623
Mailing Address - Country:US
Mailing Address - Phone:716-483-1955
Mailing Address - Fax:
Practice Address - Street 1:707 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2623
Practice Address - Country:US
Practice Address - Phone:716-483-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004127-1156FX1800X
NY4127-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00622124Medicaid