Provider Demographics
NPI:1215996517
Name:GOLLANCE, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:GOLLANCE
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 1:968 HAMBURG TPKE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3225
Mailing Address - Country:US
Mailing Address - Phone:973-696-0300
Mailing Address - Fax:973-696-0465
Practice Address - Street 1:968 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3225
Practice Address - Country:US
Practice Address - Phone:973-696-0300
Practice Address - Fax:973-696-0465
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07932300207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077283Medicaid
I44479Medicare UPIN
NJ0077283Medicaid