Healthcare Provider Details

I. General information

NPI: 1891769436
Provider Name (Legal Business Name): THOMAS D POLISOTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 ORCHARD PARK RD BUILDING C
WEST SENECA NY
14224-2646
US

IV. Provider business mailing address

338 HARRIS HILL RD SUITE 207
BUFFALO NY
14221-7470
US

V. Phone/Fax

Practice location:
  • Phone: 716-558-5153
  • Fax:
Mailing address:
  • Phone: 716-634-4798
  • Fax: 716-634-0987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number174476-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: