Provider Demographics
NPI:1164501979
Name:GYDUSH, GARY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:GYDUSH
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 1:1158 PARK CITY CTR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2726
Mailing Address - Country:US
Mailing Address - Phone:717-393-4042
Mailing Address - Fax:
Practice Address - Street 1:1158 PARK CITY CTR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2726
Practice Address - Country:US
Practice Address - Phone:717-393-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA583563JDZMedicare ID - Type Unspecified
PAT90300Medicare UPIN