Healthcare Provider Details

I. General information

NPI: 1801898978
Provider Name (Legal Business Name): GARY I POVILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 ROUTE 9W
LAKE KATRINE NY
12449-5410
US

IV. Provider business mailing address

600 WESTAGE BUSINESS CTR DR
FISHKILL NY
12524-2281
US

V. Phone/Fax

Practice location:
  • Phone: 845-231-5600
  • Fax: 845-231-5489
Mailing address:
  • Phone: 845-231-5600
  • Fax: 845-231-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number120418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: