Provider Demographics
NPI:1467948760
Name:CAMPESE, KEITH JAMES (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:CAMPESE
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 1:26 SAGEBRUSH LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-9430
Mailing Address - Country:US
Mailing Address - Phone:716-462-8519
Mailing Address - Fax:
Practice Address - Street 1:4960 TRANSIT RD STE 1
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4655
Practice Address - Country:US
Practice Address - Phone:716-462-8519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005770-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician