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General NPI Number Information
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NPI Number | 1831270701
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Entity Type | Organization
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Legal Business Name | O.D. OPTOMETRIC P.C.
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 4255 MCKINLEY PKWY
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City | HAMBURG
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State | NY
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Zip | 14075-1005
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Country | US
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Telephone | 716-646-0564
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Fax | 716-646-0571
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Provider Business Mailing Address
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Address Line | 4255 MCKINLEY PKWY INSIDE WAL-MART VISION CENTER
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City | HAMBURG
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State | NY
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Zip | 14075-1005
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Country | US
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Telephone | 716-646-0564
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES MICHAEL SAN GEORGE II
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Credential | O.D.
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Telephone | 716-646-0564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TUV006278
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License Number State | NY
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