Provider Demographics
NPI:1821113911
Name:DAVISON ROAD OPTICAL INC
Entity Type:Organization
Organization Name:DAVISON ROAD OPTICAL INC
Other - Org Name:NEWFANE FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-434-8063
Mailing Address - Street 1:500 DAVISON ROAD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094
Mailing Address - Country:US
Mailing Address - Phone:716-434-8063
Mailing Address - Fax:716-434-2845
Practice Address - Street 1:500 DAVISON ROAD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094
Practice Address - Country:US
Practice Address - Phone:716-434-8063
Practice Address - Fax:716-434-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7212222OtherINDEPENDENT HEALTH
NY330867OtherNVA
NY106166CSOtherPREFERRED CARE
NY00026473001OtherUNIVERA
NY0005901355OtherAETNA
NY149010OtherCOLE
NYNY3149OtherEYEMED
NY000300233002OtherBCBS PROV. ID
NY0005901355OtherAETNA
NY106166CSOtherPREFERRED CARE