Provider Demographics
NPI:1932295847
Name:FORD, JOHN M (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:FORD
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MAIN STREET
Mailing Address - Street 2:P.O. BOX 109
Mailing Address - City:SILVER CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:14136-0109
Mailing Address - Country:US
Mailing Address - Phone:716-934-3030
Mailing Address - Fax:716-934-4960
Practice Address - Street 1:41 MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136-1416
Practice Address - Country:US
Practice Address - Phone:716-934-3030
Practice Address - Fax:716-934-4960
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003655-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00610619Medicaid
NYSI34833BMedicare ID - Type Unspecified