Provider Demographics
NPI:1497718159
Name:BLACKLEY, JOHN C (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BLACKLEY
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 1:3364 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1439
Mailing Address - Country:US
Mailing Address - Phone:716-833-2020
Mailing Address - Fax:716-833-3854
Practice Address - Street 1:3364 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1439
Practice Address - Country:US
Practice Address - Phone:716-833-2020
Practice Address - Fax:716-833-3854
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003840-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00020027403OtherUNIVERA
NY00885272Medicaid
NY00020027403OtherUNIVERA
NY00885272Medicaid