Provider Demographics
NPI:1649748435
Name:GILLAN, EUGENE JOSEPH
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:JOSEPH
Last Name:GILLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 E HENRIETTA RD
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-9322
Mailing Address - Country:US
Mailing Address - Phone:585-334-9190
Mailing Address - Fax:
Practice Address - Street 1:2824 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9322
Practice Address - Country:US
Practice Address - Phone:585-334-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC004773-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician