Provider Demographics
NPI:1083796759
Name:WILCOX, GARY EUGENE (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:EUGENE
Last Name:WILCOX
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 1:900 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092
Mailing Address - Country:US
Mailing Address - Phone:716-754-2555
Mailing Address - Fax:716-754-8650
Practice Address - Street 1:900 CENTER STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1737
Practice Address - Country:US
Practice Address - Phone:716-754-2555
Practice Address - Fax:716-754-8650
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY40541156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0509630003Medicare ID - Type Unspecified