Healthcare Provider Details

I. General information

NPI: 1245237288
Provider Name (Legal Business Name): BRUMMITTE DALE WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 N BUFFALO ST
ORCHARD PARK NY
14127-1842
US

IV. Provider business mailing address

425 ESSJAY RD STE 170
WILLIAMSVILLE NY
14221-8235
US

V. Phone/Fax

Practice location:
  • Phone: 716-656-4494
  • Fax: 716-648-1552
Mailing address:
  • Phone: 716-630-1219
  • Fax: 716-817-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number134469
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number1344691
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: