Healthcare Provider Details

I. General information

NPI: 1891467486
Provider Name (Legal Business Name): WESTERN NEW YORK MEDICAL PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 LAC DE VILLE BLVD
ROCHESTER NY
14618-5646
US

IV. Provider business mailing address

2301 LAC DE VILLE BLVD
ROCHESTER NY
14618-5646
US

V. Phone/Fax

Practice location:
  • Phone: 585-244-0332
  • Fax:
Mailing address:
  • Phone: 585-244-0332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE S HOLDER
Title or Position: DIRECTOR - PAYER ENROLLMENT
Credential:
Phone: 585-922-0293