1073765087 NPI number — PETER MICHAEL BUFFA SR. M.D., PA

Table of content: ANDREA L DECENZO (NPI 1689104424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073765087 NPI number — PETER MICHAEL BUFFA SR. M.D., PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUFFA
Provider First Name:
PETER
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
M.D., PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073765087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEXIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76667-1516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-739-5744
Provider Business Mailing Address Fax Number:
254-739-5751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 S BONHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEXIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76667-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-739-5744
Provider Business Practice Location Address Fax Number:
254-739-5751
Provider Enumeration Date:
10/21/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  N4315 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: N4315 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209668701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".