MEDICARE: GARY E. OLIVER 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	OEG001880	PA
2	152W00000X	Optometrist	TUV005129	NY

General Provider Information

NPI Number	:	1720170251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY E. OLIVER O.D.

Provider Business Mailing Address
First Line	:	4590 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-1728
Country	:	US
Telephone Number	:	610-872-6077
Fax Number	:	610-872-2845

Provider Business Practice Location Address
First Line	:	4590 EDGMONT AVE
Second Line	:
City	:	BROOKHAVEN
State	:	PA
Zip	:	19015-1728
Country	:	US
Telephone Number	:	610-872-6077
Fax Number	:	610-872-2845

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	02/01/2017

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