Provider Demographics
NPI:1275600496
Name:PENN YAN OPTOMETRY PC
Entity Type:Organization
Organization Name:PENN YAN OPTOMETRY PC
Other - Org Name:PENN YAN EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-536-9941
Mailing Address - Street 1:163 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1284
Mailing Address - Country:US
Mailing Address - Phone:315-536-9941
Mailing Address - Fax:315-536-9321
Practice Address - Street 1:163 MAIN ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1284
Practice Address - Country:US
Practice Address - Phone:315-536-9941
Practice Address - Fax:315-536-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005146-J152W00000X, 302F00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101985CSOtherPREFERRED CARE
NY135462CTOtherPREFERRED CARE
NY11495BMedicare ID - Type Unspecified