1831270701 NPI number — O.D. OPTOMETRIC P.C.

Table of content: (NPI 1831270701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831270701 NPI number — O.D. OPTOMETRIC P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
O.D. OPTOMETRIC P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831270701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4255 MCKINLEY PKWY
Provider Second Line Business Mailing Address:
INSIDE WAL-MART VISION CENTER
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14075-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-646-0564
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4255 MCKINLEY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14075-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-646-0564
Provider Business Practice Location Address Fax Number:
716-646-0571
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAN GEORGE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-646-0564

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  TUV006278 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000390184006 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 552405 . This is a "NVA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 13693 . This is a "AVESIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 48568 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: NY6278 . This is a "COLE MANAGED VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00027038101 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 17205 . This is a "SPECTERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 919920 . This is a "BLOCK VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 988665 . This is a "CLARITY VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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