Provider Demographics
NPI:1154310266
Name:PERSIA, ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:PERSIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 EAST CHAUTAUQUA ST
Mailing Address - Street 2:PO BOX 168
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-0168
Mailing Address - Country:US
Mailing Address - Phone:716-753-7107
Mailing Address - Fax:716-753-5367
Practice Address - Street 1:42 DUNHAM AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2514
Practice Address - Country:US
Practice Address - Phone:716-665-7007
Practice Address - Fax:716-664-6131
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01816999Medicaid
NY01816999Medicaid
NYRB2996Medicare PIN
NYBB2119Medicare PIN
NYRB3479Medicare PIN
NYG61132Medicare UPIN