Provider Demographics
NPI:1083782866
Name:GERALD V HARRELL OD PC PROFESSIONAL CORPORATION NYS
Entity Type:Organization
Organization Name:GERALD V HARRELL OD PC PROFESSIONAL CORPORATION NYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-563-2430
Mailing Address - Street 1:70 COURT STREET
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2832
Mailing Address - Country:US
Mailing Address - Phone:518-563-2430
Mailing Address - Fax:518-563-2474
Practice Address - Street 1:70 COURT STREET
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2832
Practice Address - Country:US
Practice Address - Phone:518-563-2430
Practice Address - Fax:518-563-2474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT0026841152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00623405Medicaid
NY00623405Medicaid