Provider Demographics
NPI:1720170251
Name:OLIVER, GARY E (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:OLIVER
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 1:4590 EDGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-1728
Mailing Address - Country:US
Mailing Address - Phone:610-872-6077
Mailing Address - Fax:610-872-2845
Practice Address - Street 1:4590 EDGMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-1728
Practice Address - Country:US
Practice Address - Phone:610-872-6077
Practice Address - Fax:610-872-2845
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001880152W00000X
NYTUV005129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC4258Medicare UPIN