Healthcare Provider Details

I. General information

NPI: 1104816065
Provider Name (Legal Business Name): MARK R KLOCKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 N BAILEY AVE
AMHERST NY
14226-5102
US

IV. Provider business mailing address

6000 N BAILEY AVE
AMHERST NY
14226-5102
US

V. Phone/Fax

Practice location:
  • Phone: 716-834-4522
  • Fax: 716-834-6191
Mailing address:
  • Phone: 716-834-4522
  • Fax: 716-834-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number182253
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier040426001490
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerFIDELIS
# 2
Identifier00010092105
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerUNIVERA
# 3
Identifier01245578
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 4
Identifier000511134005
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerBC/BS
# 5
Identifier1208952
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerIHA
# 6
Identifier143849DL
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerPREFERRED CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: