Provider Demographics
NPI:1124012802
Name:RETINA SPECIALIST OF THE FINGER LAKES
Entity Type:Organization
Organization Name:RETINA SPECIALIST OF THE FINGER LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHI-HWA
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-254-2260
Mailing Address - Street 1:2300 BUFFALO RD
Mailing Address - Street 2:BLDG 700B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1360
Mailing Address - Country:US
Mailing Address - Phone:585-254-2260
Mailing Address - Fax:585-254-4035
Practice Address - Street 1:2300 BUFFALO RD
Practice Address - Street 2:BLDG 700B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1360
Practice Address - Country:US
Practice Address - Phone:585-254-2260
Practice Address - Fax:585-254-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199170207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G0189901590OtherBLUE CHOICE
NY02527553Medicaid
G0189901590OtherBLUE CHOICE