Provider Demographics
NPI:1760479356
Name:IRISH, GARY B (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:B
Last Name:IRISH
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 1:87 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3234
Mailing Address - Country:US
Mailing Address - Phone:802-878-6830
Mailing Address - Fax:802-878-6315
Practice Address - Street 1:87 MAIN ST
Practice Address - Street 2:
Practice Address - City:ESSEX JCT
Practice Address - State:VT
Practice Address - Zip Code:05452-3234
Practice Address - Country:US
Practice Address - Phone:802-878-6830
Practice Address - Fax:802-878-6315
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT58749OtherBCBS
VT6168371OtherCIGNA
VT59V024OtherMVP
VT030427694OtherCBA
VT59298OtherVERMONT MANAGED CARE
VT4664770001Medicare NSC
VT59V024OtherMVP
VTT25410Medicare UPIN