Healthcare Provider Details

I. General information

NPI: 1295924363
Provider Name (Legal Business Name): TONAWANDA MEDICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 TONAWANDA ST
BUFFALO NY
14207-1447
US

IV. Provider business mailing address

PO BOX 1015
BUFFALO NY
14207-9015
US

V. Phone/Fax

Practice location:
  • Phone: 716-536-9409
  • Fax: 716-874-6660
Mailing address:
  • Phone: 716-536-9409
  • Fax: 716-689-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number214045
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number214045
License Number StateNY

VIII. Authorized Official

Name: DR. ZIAD I KHATIB
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 716-536-9409