Provider Demographics
NPI:1629659909
Name:GIBEAULT, JEFFREY ADAM (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ADAM
Last Name:GIBEAULT
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:VALATIE
Mailing Address - State:NY
Mailing Address - Zip Code:12184-4803
Mailing Address - Country:US
Mailing Address - Phone:518-364-3242
Mailing Address - Fax:
Practice Address - Street 1:12 BIRCH RD
Practice Address - Street 2:
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-4803
Practice Address - Country:US
Practice Address - Phone:518-364-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008095-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician