Individual
KEVIN BRADLEY WYNNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
56 STATE ST, PITTSFORD, NY 14534-2344
(585) 381-4640
(585) 381-3322
Mailing address
56 STATE ST, PITTSFORD, NY 14534-2344
(585) 381-4640
(585) 381-3322
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
TUV005374
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
102002CS
PREFERRED CARE
NY
01
—
14929A
MEDICARE GROUP #
—
01
—
7100219
AETNA
NY
01
—
PO10005374
BLUE CHOICE
NY
Enumeration date
10/03/2005
Last updated
10/17/2022
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