Provider Demographics
NPI:1831103464
Name:WESTFALL, PAUL JEROME (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEROME
Last Name:WESTFALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3252
Mailing Address - Country:US
Mailing Address - Phone:518-792-5711
Mailing Address - Fax:518-792-5723
Practice Address - Street 1:15 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3008
Practice Address - Country:US
Practice Address - Phone:518-792-5711
Practice Address - Fax:518-792-5723
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2652152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTV04329Medicare UPIN
CT410001162Medicare PIN