Provider Demographics
NPI:1699899617
Name:VERONNEAU, GARY G
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:VERONNEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1298
Mailing Address - Country:US
Mailing Address - Phone:304-438-8574
Mailing Address - Fax:304-438-8753
Practice Address - Street 1:1102 MAIN ST
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1298
Practice Address - Country:US
Practice Address - Phone:304-438-8574
Practice Address - Fax:304-438-8753
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV753D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150799000Medicaid
WV0711730001Medicare NSC
WV0579131Medicare ID - Type Unspecified