Provider Demographics
NPI:1043583727
Name:WJW OPTOMETRY PC
Entity Type:Organization
Organization Name:WJW OPTOMETRY PC
Other - Org Name:GRAND ISLAND OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:716-510-4046
Mailing Address - Street 1:2099 GRAND ISLAND BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2060
Mailing Address - Country:US
Mailing Address - Phone:716-773-7653
Mailing Address - Fax:716-773-3187
Practice Address - Street 1:2099 GRAND ISLAND BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2060
Practice Address - Country:US
Practice Address - Phone:716-773-7653
Practice Address - Fax:716-773-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-11
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYV005582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU57329Medicare UPIN