Provider Demographics
NPI:1760557508
Name:WESTERN NEW YORK RETINA PLLC
Entity Type:Organization
Organization Name:WESTERN NEW YORK RETINA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-204-5440
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:STE 208
Mailing Address - City:N TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-2160
Mailing Address - Fax:716-213-0935
Practice Address - Street 1:5225 SHERIDAN DR
Practice Address - Street 2:GEORGETOWN SQUARE PLAZA
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3573
Practice Address - Country:US
Practice Address - Phone:716-204-5440
Practice Address - Fax:716-204-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217838207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02097863Medicaid
NY02097863Medicaid