Provider Demographics
NPI:1013331909
Name:DR GARY A EAGLE LLC
Entity Type:Organization
Organization Name:DR GARY A EAGLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:973-325-0500
Mailing Address - Street 1:414 EAGLE ROCK AVE
Mailing Address - Street 2:SUITE 206A
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4229
Mailing Address - Country:US
Mailing Address - Phone:973-325-0500
Mailing Address - Fax:973-325-0075
Practice Address - Street 1:414 EAGLE ROCK AVENUE
Practice Address - Street 2:SUITE 206A
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4224
Practice Address - Country:US
Practice Address - Phone:973-325-0500
Practice Address - Fax:973-325-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00457500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ115334Medicare UPIN