Provider Demographics
NPI:1215279740
Name:PATERNO, MICHAEL R (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:PATERNO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 THORNFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3049
Mailing Address - Country:US
Mailing Address - Phone:585-223-9272
Mailing Address - Fax:
Practice Address - Street 1:50 COBBLESTONE COURT DR
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1044
Practice Address - Country:US
Practice Address - Phone:585-425-1770
Practice Address - Fax:585-425-2770
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU49731Medicaid
NYU49731Medicaid