Provider Demographics
NPI:1093810830
Name:EYESIGHT OPHTHALMOLOGY P.C.
Entity Type:Organization
Organization Name:EYESIGHT OPHTHALMOLOGY P.C.
Other - Org Name:EYESIGHT MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:STATHOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-517-0680
Mailing Address - Street 1:4041 DELAWARE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6850
Mailing Address - Country:US
Mailing Address - Phone:716-837-5200
Mailing Address - Fax:716-837-8750
Practice Address - Street 1:4041 DELAWARE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6850
Practice Address - Country:US
Practice Address - Phone:716-837-5200
Practice Address - Fax:716-837-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205998207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00603329Medicaid
NY1168860001Medicare NSC
NYAA1002Medicare ID - Type Unspecified
NYB35965Medicare UPIN