MEDICARE: DR. GARY B IRISH 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	0300000141	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58749	OTHER	VT	BCBS
2	6168371	OTHER	VT	CIGNA
3	59V024	OTHER	VT	MVP
4	030427694	OTHER	VT	CBA
5	59298	OTHER	VT	VERMONT MANAGED CARE

General Provider Information

NPI Number	:	1760479356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY B IRISH O.D.

Provider Business Mailing Address
First Line	:	87 MAIN ST
Second Line	:
City	:	ESSEX JCT
State	:	VT
Zip	:	05452-3234
Country	:	US
Telephone Number	:	802-878-6830
Fax Number	:	802-878-6315

Provider Business Practice Location Address
First Line	:	87 MAIN ST
Second Line	:
City	:	ESSEX JCT
State	:	VT
Zip	:	05452-3234
Country	:	US
Telephone Number	:	802-878-6830
Fax Number	:	802-878-6315

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	04/30/2010

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