Provider Demographics
NPI:1336292119
Name:KIMACK, DONNA (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:
Last Name:KIMACK
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 BACK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:NY
Mailing Address - Zip Code:14025-9702
Mailing Address - Country:US
Mailing Address - Phone:716-941-9150
Mailing Address - Fax:
Practice Address - Street 1:1161 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2701
Practice Address - Country:US
Practice Address - Phone:716-824-2631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004790-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVUT004790-1OtherLICENSE
NY000390033002OtherBCBS COMMUNITY BLUE