Provider Demographics
NPI:1386611358
Name:RUNDQUIST, JOHN DARRYL (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DARRYL
Last Name:RUNDQUIST
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 1:35 S JERGE DR
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9306
Mailing Address - Country:US
Mailing Address - Phone:716-652-5375
Mailing Address - Fax:
Practice Address - Street 1:4511 MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3809
Practice Address - Country:US
Practice Address - Phone:716-839-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT-005853152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
U-70565Medicare UPIN
CC9156Medicare PIN