Provider Demographics
NPI:1609084524
Name:PARK SHER OPTICAL CO OF BUFFALO NY INC
Entity Type:Organization
Organization Name:PARK SHER OPTICAL CO OF BUFFALO NY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:716-822-2264
Mailing Address - Street 1:3876 SOUTH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219
Mailing Address - Country:US
Mailing Address - Phone:716-822-2264
Mailing Address - Fax:
Practice Address - Street 1:3876 S PARK AVE
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-1800
Practice Address - Country:US
Practice Address - Phone:716-822-2264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 156FX1800X
NYTUV006414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0212580002Medicare NSC