Provider Demographics
NPI:1710039797
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:SOUTHGATE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-649-1035
Mailing Address - Street 1:1028B UNION RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1028B UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-674-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NYTUV002858152W00000X, 152WC0802X
NYT006096152WC0802X
NYC004425156FC0800X, 156FC0801X, 156FX1100X, 156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Not Answered156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
Not Answered156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003002352OtherBLUE CROSS BLUE SHIELD
NY161411390OtherSUPERIOR VISION SERVICES
NY00025795401OtherUNIVERA
NY333696OtherNVA
NYNY4425OtherEYEMED
NY17662OtherSPECTERA