MEDICARE: MR. GARY EUGENE WILCOX OPTICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	40541	NY

General Provider Information

NPI Number	:	1083796759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY EUGENE WILCOX OPTICIAN

Provider Business Mailing Address
First Line	:	900 CENTER ST
Second Line	:
City	:	LEWISTON
State	:	NY
Zip	:	14092
Country	:	US
Telephone Number	:	716-754-2555
Fax Number	:	716-754-8650

Provider Business Practice Location Address
First Line	:	900 CENTER STREET
Second Line	:
City	:	LEWISTON
State	:	NY
Zip	:	14092-1737
Country	:	US
Telephone Number	:	716-754-2555
Fax Number	:	716-754-8650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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