Provider Demographics
NPI:1275820441
Name:REDEYE, VIVIEN LEAH (MD)
Entity type:Individual
Prefix:
First Name:VIVIEN
Middle Name:LEAH
Last Name:REDEYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6968
Mailing Address - Country:US
Mailing Address - Phone:716-338-0022
Mailing Address - Fax:
Practice Address - Street 1:3780 EAGLE ST
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-9410
Practice Address - Country:US
Practice Address - Phone:716-672-3030
Practice Address - Fax:716-338-1567
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88402208M00000X, 207Q00000X
NY60276182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC884029Medicaid