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General NPI Number Information
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NPI Number | 1629177134
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Entity Type | Organization
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Legal Business Name | LEWISTON VILLAGE PEDIATRICS
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 08/04/2016
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Provider Practice Location Address
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Address Line | 733 CENTER STREET
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City | LEWISTON
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State | NY
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Zip | 14092
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Country | US
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Telephone | 716-754-7337
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Fax | 716-754-2041
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Provider Business Mailing Address
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Address Line | 733 CENTER STREET
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City | LEWISTON
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State | NY
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Zip | 14092
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Country | US
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Telephone | 716-754-7337
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Fax | 716-754-2041
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. SHAWN P FERGUSON
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Credential | M.D.
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Telephone | 716-754-7337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 131077
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License Number State | NY
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