Healthcare Provider Details

I. General information

NPI: 1730423807
Provider Name (Legal Business Name): THANYANAN REUNGWETWATTANA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSWELL PARK CANCER INSTITUTE ELM & CARLTON STREETS
BUFFALO NY
14263-0001
US

IV. Provider business mailing address

275B EVANS ST APT # 6
WILLIAMSVILLE NY
14221-5666
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-4101
  • Fax: 716-845-3423
Mailing address:
  • Phone: 507-319-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberP86261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: