Healthcare Provider Details

I. General information

NPI: 1912169681
Provider Name (Legal Business Name): MICHAEL THOMAS GUPPENBERGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 GENESEE ST SUITE 200
BOWMANSVILLE NY
14026-1044
US

IV. Provider business mailing address

1526 WALDEN AVENUE SUITE 400
CHEEKTOWAGA NY
14225-4985
US

V. Phone/Fax

Practice location:
  • Phone: 716-681-5077
  • Fax: 716-887-5801
Mailing address:
  • Phone: 716-655-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number249112-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: