Provider Demographics
NPI:1053444950
Name:SELBERT, GARY STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:STEVEN
Last Name:SELBERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-4504
Mailing Address - Country:US
Mailing Address - Phone:518-842-2480
Mailing Address - Fax:518-842-3409
Practice Address - Street 1:42 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-4504
Practice Address - Country:US
Practice Address - Phone:518-842-2480
Practice Address - Fax:518-842-3409
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTOO2983-1152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0850710001Medicare NSC