Provider Demographics
NPI:1194784694
Name:DOTTERWEICH, JENNIFER J (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:DOTTERWEICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:NY
Mailing Address - Zip Code:14414-1421
Mailing Address - Country:US
Mailing Address - Phone:585-519-4208
Mailing Address - Fax:585-438-4148
Practice Address - Street 1:243 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:NY
Practice Address - Zip Code:14414-1421
Practice Address - Country:US
Practice Address - Phone:585-519-4208
Practice Address - Fax:585-438-4148
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA4488Medicare ID - Type Unspecified
NYU86791Medicare UPIN