Healthcare Provider Details

I. General information

NPI: 1720084346
Provider Name (Legal Business Name): MICHAEL D DEPAOLIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 RUE DE VL
ROCHESTER NY
14618-5619
US

IV. Provider business mailing address

16 RANDOM WOODS
PITTSFORD NY
14534-1440
US

V. Phone/Fax

Practice location:
  • Phone: 585-271-2990
  • Fax:
Mailing address:
  • Phone: 585-586-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4109
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTUV004109-0
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: