Healthcare Provider Details

I. General information

NPI: 1124012802
Provider Name (Legal Business Name): RETINA SPECIALIST OF THE FINGER LAKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 BUFFALO RD BLDG 700B
ROCHESTER NY
14624-1360
US

IV. Provider business mailing address

2300 BUFFALO RD BLDG 700B
ROCHESTER NY
14624-1360
US

V. Phone/Fax

Practice location:
  • Phone: 585-254-2260
  • Fax: 585-254-4035
Mailing address:
  • Phone: 585-254-2260
  • Fax: 585-254-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number199170
License Number StateNY

VIII. Authorized Official

Name: SHI-HWA WILLIAM CHANG
Title or Position: PRESIDENT
Credential: MD
Phone: 585-254-2260