1437115482 NPI number — DR. LISETTE ANNE D'EON MD

Table of content: DR. LISETTE ANNE D'EON MD (NPI 1437115482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437115482 NPI number — DR. LISETTE ANNE D'EON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
D'EON
Provider First Name:
LISETTE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1437115482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 GETZVILLE RD
Provider Second Line Business Mailing Address:
APT. C
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14226-3516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-832-5901
Provider Business Mailing Address Fax Number:
716-961-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 E MAIN ST
Provider Second Line Business Practice Location Address:
BERTRAND CHAFFEE HOSPITAL PRIMARY CARE CLINIC
Provider Business Practice Location Address City Name:
SPRINGVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14141-1443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-592-8140
Provider Business Practice Location Address Fax Number:
716-961-3713
Provider Enumeration Date:
04/26/2006

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: 207R00000X , with the licence number:  185096 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01345179 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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