Provider Demographics
NPI:1972513273
Name:MOHAWK VALLEY RETINA, PLLC
Entity Type:Organization
Organization Name:MOHAWK VALLEY RETINA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-732-0995
Mailing Address - Street 1:83 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2334
Mailing Address - Country:US
Mailing Address - Phone:315-732-0995
Mailing Address - Fax:315-732-0689
Practice Address - Street 1:4350 MIDDLE SETTLEMENT RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-5345
Practice Address - Country:US
Practice Address - Phone:315-732-0995
Practice Address - Fax:315-732-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208523207W00000X
NY223258207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1063Medicare ID - Type Unspecified