Healthcare Provider Details

I. General information

NPI: 1194784694
Provider Name (Legal Business Name): JENNIFER J DOTTERWEICH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 E MAIN ST
AVON NY
14414-1421
US

IV. Provider business mailing address

243 E MAIN ST
AVON NY
14414-1421
US

V. Phone/Fax

Practice location:
  • Phone: 585-519-4208
  • Fax: 585-438-4148
Mailing address:
  • Phone: 585-519-4208
  • Fax: 585-438-4148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6150
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: