Healthcare Provider Details

I. General information

NPI: 1033484894
Provider Name (Legal Business Name): GREATER BUFFALO UNITED IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 NIAGARA ST
BUFFALO NY
14201
US

IV. Provider business mailing address

564 NIAGARA ST
BUFFALO NY
14201-1108
US

V. Phone/Fax

Practice location:
  • Phone: 716-882-0366
  • Fax: 716-830-4840
Mailing address:
  • Phone: 716-882-0366
  • Fax: 716-830-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number185052
License Number StateNY

VIII. Authorized Official

Name: DR. RAUL VAZQUEZ
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 716-882-0366