Provider Demographics
NPI:1821087248
Name:JAMESTOWN OPTOMETRIC GROUP, PC
Entity Type:Organization
Organization Name:JAMESTOWN OPTOMETRIC GROUP, PC
Other - Org Name:SPECTRUM EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:716-664-7601
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:716-664-3353
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003318-1152W00000X
NYTUV003267-1152W00000X
NYTUV005272-1152W00000X
NYTUV006073-1152W00000X
NC1750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCA3840OtherMETRA HEALTH RAILROAD
NYY051712OtherTRICARE
NY30926AMedicare ID - Type UnspecifiedUPSTATE MEDICARE
NY0253570001Medicare NSC