Provider Demographics
NPI:1194798165
Name:PROULX, GARY MILLER (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MILLER
Last Name:PROULX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9370
Mailing Address - Fax:315-870-9364
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4597
Practice Address - Country:US
Practice Address - Phone:978-687-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206678-12085R0001X
PAMD4199712085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00362286OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
PA0016314520003Medicaid
NY01753942Medicaid
PA920007329OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
PA0016314520003Medicaid
PA063010N87Medicare ID - Type Unspecified