Healthcare Provider Details

I. General information

NPI: 1467614172
Provider Name (Legal Business Name): MICHAEL R NAZARETH M.D./PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 SPINDRIFT DR SUITE 100
WILLIAMSVILLE NY
14221-7894
US

IV. Provider business mailing address

297 SPINDRIFT DR SUITE 100
WILLIAMSVILLE NY
14221-7894
US

V. Phone/Fax

Practice location:
  • Phone: 716-831-2600
  • Fax: 716-831-2601
Mailing address:
  • Phone: 716-831-2600
  • Fax: 716-831-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number254917
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: