Healthcare Provider Details

I. General information

NPI: 1245209634
Provider Name (Legal Business Name): GARY ROBERT NELSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 N BENZING RD
ORCHARD PARK NY
14127-1538
US

IV. Provider business mailing address

40 LA RIVIERE DR STE 201
BUFFALO NY
14202-4344
US

V. Phone/Fax

Practice location:
  • Phone: 716-972-0300
  • Fax: 716-972-0309
Mailing address:
  • Phone: 716-893-1010
  • Fax: 716-893-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number164038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: