Provider Demographics
NPI:1881750024
Name:EAGLE, GARY A (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:EAGLE
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 1:414 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 AVE
Practice Address - Street 2:SUITE 206A
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4229
Practice Address - Country:US
Practice Address - Phone:973-325-0500
Practice Address - Fax:973-325-0075
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ115334Medicare ID - Type Unspecified