Provider Demographics
NPI:1235111089
Name:WEBER, PAMELA A
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:WEBER
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 1:1500 WILLIAM FLOYD PKWY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967
Mailing Address - Country:US
Mailing Address - Phone:631-924-4300
Mailing Address - Fax:631-924-2525
Practice Address - Street 1:1500 WILLIAM FLOYD PKWY
Practice Address - Street 2:SUITE 304
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967
Practice Address - Country:US
Practice Address - Phone:631-924-4300
Practice Address - Fax:631-924-2525
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1657721207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01184812Medicaid
42F851Medicare PIN
NY01184812Medicaid