Healthcare Provider Details

I. General information

NPI: 1649260118
Provider Name (Legal Business Name): NICHOLAS TIBERIA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 SOUTHWESTERN BLVD STE 203
ORCHARD PARK NY
14127-1233
US

IV. Provider business mailing address

69 CEDAR RIDGE DR
WEST SENECA NY
14224-2574
US

V. Phone/Fax

Practice location:
  • Phone: 716-674-0375
  • Fax: 716-677-2965
Mailing address:
  • Phone: 716-675-4417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003294-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: