Provider Demographics
NPI:1912968140
Name:GULLOTTI, THOMAS S (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
Last Name:GULLOTTI
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 1:560 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-4776
Mailing Address - Country:US
Mailing Address - Phone:716-484-0325
Mailing Address - Fax:
Practice Address - Street 1:560 W 3RD ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4776
Practice Address - Country:US
Practice Address - Phone:716-484-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31424BOtherMEDICARE
NY31424BOtherMEDICARE
NYT26311Medicare UPIN