Provider Demographics
NPI:1376016089
Name:PHILLIPS, JOSEPH W
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:W
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:886 NIAGARA FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2006
Mailing Address - Country:US
Mailing Address - Phone:716-243-4159
Mailing Address - Fax:716-692-1238
Practice Address - Street 1:886 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-2006
Practice Address - Country:US
Practice Address - Phone:716-243-4159
Practice Address - Fax:716-692-1238
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC005191-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician