Basic Information
| Provider Information | |||||||||
| NPI: | 1093836991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPAOLIS AND RYAN OD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 RUE DE VL | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146185619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852712990 | ||||||||
| FaxNumber: | 5852716321 | ||||||||
| Practice Location | |||||||||
| Address1: | 169 RUE DE VL | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146185619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852712990 | ||||||||
| FaxNumber: | 5852716321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 5852712990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 005025 | NY | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 017410959 | 01 | NY | BLUE CHOICE | OTHER |