MEDICARE: DR. GARY ALBERT MINECONZO O.D.

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	152W00000X	Optometrist	T003570-1	NY

General Provider Information

NPI Number	:	1700971397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ALBERT MINECONZO O.D.

Provider Business Mailing Address
First Line	:	98 ROCKWELL RD
Second Line	:
City	:	QUEENSBURY
State	:	NY
Zip	:	12804-7739
Country	:	US
Telephone Number	:	518-793-2857
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 AVIATION RD
Second Line	:
City	:	QUEENSBURY
State	:	NY
Zip	:	12804-1842
Country	:	US
Telephone Number	:	518-798-6923
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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