MEDICARE: DR. GARY L DILLON JR. PHD

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	103T00000X	Psychologist	023245	NY

General Provider Information

NPI Number	:	1679109714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY L DILLON JR. PHD

Provider Business Mailing Address
First Line	:	90 STATE ST STE OFFICE40
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12207-1716
Country	:	US
Telephone Number	:	347-770-2559
Fax Number	:

Provider Business Practice Location Address
First Line	:	137 E 25TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-2314
Country	:	US
Telephone Number	:	516-777-0661
Fax Number	:

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

Provider Enumeration Date	:	03/20/2020
Last Update Date	:	02/06/2021

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