Provider Demographics
NPI:1598712846
Name:PISANCHYN, GARY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:PISANCHYN
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 1:530 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-3300
Mailing Address - Country:US
Mailing Address - Phone:607-729-5016
Mailing Address - Fax:607-729-7574
Practice Address - Street 1:530 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-3300
Practice Address - Country:US
Practice Address - Phone:607-729-5016
Practice Address - Fax:607-729-7574
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004514-1152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00974465Medicaid
34748KMedicare UPIN
NY00974465Medicaid
U27221Medicare UPIN
0834230003Medicare NSC