Basic Information
| Provider Information | |||||||||
| NPI: | 1154310266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERSIA | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 EAST CHAUTAUQUA ST | ||||||||
| Address2: | PO BOX 168 | ||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 DUNHAM AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147012514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166657007 | ||||||||
| FaxNumber: | 7166646131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 04/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 210053 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01816999 | 05 | NY | MEDICAID |