Healthcare Provider Details

I. General information

NPI: 1851865513
Provider Name (Legal Business Name): CAPITAL REGION PEDIATRIC MEDICAL EYE CONSULTANT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 09/01/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 ALBANY SHAKER RD STE 101
LATHAM NY
12110-1468
US

IV. Provider business mailing address

920 ALBANY SHAKER RD STE 101
LATHAM NY
12110-1468
US

V. Phone/Fax

Practice location:
  • Phone: 518-533-6502
  • Fax: 518-533-6505
Mailing address:
  • Phone: 518-533-6502
  • Fax: 518-533-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GERARD BARRY
Title or Position: OWNER
Credential: MD
Phone: 518-533-6502