Provider Demographics
NPI:1356318257
Name:BIRD, PETER (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BIRD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2907
Mailing Address - Country:US
Mailing Address - Phone:585-872-1300
Mailing Address - Fax:585-872-5397
Practice Address - Street 1:1015 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2907
Practice Address - Country:US
Practice Address - Phone:585-872-1300
Practice Address - Fax:585-872-5397
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005418-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01492433Medicaid
NYU43873Medicare UPIN
NY14167BMedicare ID - Type Unspecified