Healthcare Provider Details

I. General information

NPI: 1215193214
Provider Name (Legal Business Name): VICKI IP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 LAWN AVE
BUFFALO NY
14207-1816
US

IV. Provider business mailing address

155 LAWN AVE
BUFFALO NY
14207-1816
US

V. Phone/Fax

Practice location:
  • Phone: 716-875-2904
  • Fax: 716-875-6717
Mailing address:
  • Phone: 716-875-2904
  • Fax: 716-875-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number003895-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: