Provider Demographics
NPI:1518956929
Name:MOLE', HENRY W (OD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:W
Last Name:MOLE'
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 1:555 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2750
Mailing Address - Country:US
Mailing Address - Phone:716-664-7601
Mailing Address - Fax:
Practice Address - Street 1:555 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2750
Practice Address - Country:US
Practice Address - Phone:716-664-7601
Practice Address - Fax:716-664-3353
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005272-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5362684OtherAETNA US HEALTHCARE
NY003901291OtherBLUE CROSS OF WNY
NY410026682OtherMETRA HEALTH RAILROAD
NY00025522301OtherUNIVERA HEALTHCARE
NY30926GMedicare ID - Type UnspecifiedUPSTATE MEDICARE
NYU22604Medicare UPIN