Healthcare Provider Details

I. General information

NPI: 1275600496
Provider Name (Legal Business Name): PENN YAN OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 MAIN ST
PENN YAN NY
14527-1284
US

IV. Provider business mailing address

163 MAIN ST
PENN YAN NY
14527-1284
US

V. Phone/Fax

Practice location:
  • Phone: 315-536-9941
  • Fax: 315-536-9321
Mailing address:
  • Phone: 315-536-9941
  • Fax: 315-536-9321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005146-J
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberTUV005146-J
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberTUV005146-J
License Number StateNY

VIII. Authorized Official

Name: DR. ANDREW PAUL SMITH
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 315-536-9941