Healthcare Provider Details

I. General information

NPI: 1467478776
Provider Name (Legal Business Name): WALTER R BURACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/05/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 626
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

PO BOX 626 601 ELMWOOD AVENUE
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-273-1885
  • Fax: 585-276-2047
Mailing address:
  • Phone: 585-273-1885
  • Fax: 585-276-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number243435
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number243435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: