Healthcare Provider Details

I. General information

NPI: 1699787648
Provider Name (Legal Business Name): DAVID KAUFMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 THURBER DR
WATERLOO NY
13165-1600
US

IV. Provider business mailing address

31 THURBER DR
WATERLOO NY
13165-1600
US

V. Phone/Fax

Practice location:
  • Phone: 315-539-1980
  • Fax: 315-539-1054
Mailing address:
  • Phone: 315-539-1980
  • Fax: 315-539-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number170570
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier170570
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: