Healthcare Provider Details

I. General information

NPI: 1609583228
Provider Name (Legal Business Name): GJKS PHYSICIAN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 MILITARY RD
NIAGARA FALLS NY
14305-1335
US

IV. Provider business mailing address

4515 MILITARY RD
NIAGARA FALLS NY
14305-1335
US

V. Phone/Fax

Practice location:
  • Phone: 716-236-7880
  • Fax: 716-236-7885
Mailing address:
  • Phone: 716-236-7880
  • Fax: 716-236-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAITLYNN LESTER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 716-236-7880