Provider Demographics
NPI:1154494045
Name:DOE, ERYN MAE
Entity Type:Individual
Prefix:MS
First Name:ERYN
Middle Name:MAE
Last Name:DOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LYON PLACE SUITE 101
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2590
Mailing Address - Country:US
Mailing Address - Phone:315-393-3937
Mailing Address - Fax:315-393-0591
Practice Address - Street 1:3 LYON PLACE SUITE 101
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2590
Practice Address - Country:US
Practice Address - Phone:315-393-3937
Practice Address - Fax:315-393-0591
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0079491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02580876Medicaid