Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 094920 | NY |
NPI | 1003801366 |
---|---|
Provider Name | Dr. Leo Michael Michalek JR. |
First Address | West Seneca, NY 14224 |
Second Address | Lackawanna, NY 14218-1319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2005 |
Last Update Date | 05/05/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00010118401 | UNIVERA (01) | |
000505334001 | BCBS (01) | |
00601643 | (05) | NY |
1700291 | IHA (01) | |
C58031 | (02) |