Provider Demographics
NPI:1114039302
Name:GEORGE, GILLIAN (OD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LYDECKER ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1914
Mailing Address - Country:US
Mailing Address - Phone:201-906-1376
Mailing Address - Fax:
Practice Address - Street 1:2376 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-6907
Practice Address - Country:US
Practice Address - Phone:718-365-6300
Practice Address - Fax:718-365-5620
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006888152W00000X
NJ27OA00592600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0050865Medicaid
NY03498217Medicaid
NJ0050865Medicaid
NJV02745Medicare UPIN