Healthcare Provider Details

I. General information

NPI: 1265750178
Provider Name (Legal Business Name): VIDYA PREMANAND NAGRALE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIDYA SUDEEP INGOLE MD

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

IV. Provider business mailing address

ELM AND CARLTON ST
BUFFALO NY
14263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax: 716-845-3549
Mailing address:
  • Phone: 716-845-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number274937
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125058857
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number274937
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number274937
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number274937
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number274937
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number274937
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number274937
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: