=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437352192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROCKPORT OPTOMETRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 03/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 N MAIN ST LOWER SUITE
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-637-2121
-----------------------------------------------------
Fax | 585-637-7722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 FARM FIELD LN
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-2865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-248-2141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. MICHAEL LEE RAFF
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 585-637-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------