Basic Information
| Provider Information | |||||||||
| NPI: | 1538200639 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAFAYETTE FAMILY OPTOMETRY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6157 US ROUTE 20 | ||||||||
| Address2: | |||||||||
| City: | LA FAYETTE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130843404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156773193 | ||||||||
| FaxNumber: | 3156773196 | ||||||||
| Practice Location | |||||||||
| Address1: | 6157 RT 20 E | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156773193 | ||||||||
| FaxNumber: | 3156773196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3156773193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | AA0619 | 01 | NY | PTAN | OTHER |