Healthcare Provider Details

I. General information

NPI: 1033372305
Provider Name (Legal Business Name): POLLYANNA L ROACH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 HAMLIN AVE
EAST AURORA NY
14052-1604
US

IV. Provider business mailing address

65 HAMLIN AVE
EAST AURORA NY
14052-1604
US

V. Phone/Fax

Practice location:
  • Phone: 716-341-2270
  • Fax:
Mailing address:
  • Phone: 716-341-2270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007310
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: