Provider Demographics
NPI:1588653661
Name:FARRELL, GAULT M (MD)
Entity Type:Individual
Prefix:DR
First Name:GAULT
Middle Name:M
Last Name:FARRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1755
Mailing Address - Country:US
Mailing Address - Phone:518-566-2020
Mailing Address - Fax:518-561-5390
Practice Address - Street 1:450 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1755
Practice Address - Country:US
Practice Address - Phone:518-566-2020
Practice Address - Fax:518-561-5390
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213607174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
213607OtherLICENSE
NY000402108001OtherBLUE SHIELD OF NORTHEASTE
NY424B3OtherEMPIRE BLUE CROSS
NY01433123Medicaid
2136077OtherWC
400638OtherMVP SELECT CARE
107286OtherBC UTICA
107286OtherBC UTICA
NYDD1801Medicare ID - Type Unspecified
NY424B3OtherEMPIRE BLUE CROSS
107286OtherBC UTICA