Healthcare Provider Details

I. General information

NPI: 1588686471
Provider Name (Legal Business Name): SAMRET YAUKOOLBODI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 02/10/2012
Certification Date:
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 STE B252
BUFFALO NY
14203-1126
US

V. Phone/Fax

Practice location:
  • Phone: 716-852-1977
  • Fax: 716-859-7388
Mailing address:
  • Phone: 716-852-1977
  • Fax: 716-859-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number137351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: