Healthcare Provider Details

I. General information

NPI: 1013658442
Provider Name (Legal Business Name): MR. JACK RYAN PEREZ-PEREZ HODGKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK RYAN HODGKINS

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGH ST
BUFFALO NY
14203-1126
US

IV. Provider business mailing address

100 HIGH ST
BUFFALO NY
14203-1126
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-6104
  • Fax:
Mailing address:
  • Phone: 716-829-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number343222-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: