Provider Demographics
NPI:1508932229
Name:COURT, GARTH A (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GARTH
Middle Name:A
Last Name:COURT
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 1:204 MAIN ST SHOP CENTRE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165
Mailing Address - Country:US
Mailing Address - Phone:315-539-1209
Mailing Address - Fax:315-539-1209
Practice Address - Street 1:204 MAIN ST SHOP CENTRE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165
Practice Address - Country:US
Practice Address - Phone:315-539-1209
Practice Address - Fax:315-539-1209
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4388156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
103006CTOtherPREFERRED CARE
4355030001Medicare ID - Type Unspecified