Healthcare Provider Details

I. General information

NPI: 1619389509
Provider Name (Legal Business Name): NIAGARA EAR NOSE & THROAT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7731 PORTER RD
NIAGARA FALLS NY
14304-1681
US

IV. Provider business mailing address

7731 PORTER RD
NIAGARA FALLS NY
14304-1681
US

V. Phone/Fax

Practice location:
  • Phone: 716-575-0075
  • Fax: 716-242-0611
Mailing address:
  • Phone: 716-575-0075
  • Fax: 716-242-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number257426
License Number StateNY

VIII. Authorized Official

Name: JUSTIN D MILLER
Title or Position: PRESIDENT
Credential: MD
Phone: 716-535-0741