Healthcare Provider Details

I. General information

NPI: 1285612010
Provider Name (Legal Business Name): JEFFREY A BUETIKOFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 MYRTLE STREET SUITE 190
ERIE PA
16502-4604
US

IV. Provider business mailing address

2315 MYRTLE STREET SUITE 190
ERIE PA
16502-4604
US

V. Phone/Fax

Practice location:
  • Phone: 814-453-7767
  • Fax: 814-454-6667
Mailing address:
  • Phone: 814-453-7767
  • Fax: 814-454-6667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD041659L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberMD041659L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: