Provider Demographics
NPI:1104810944
Name:DEPNER, CHRISTOPHER R (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:DEPNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1057
Mailing Address - Country:US
Mailing Address - Phone:585-593-4250
Mailing Address - Fax:585-593-2465
Practice Address - Street 1:12 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:585-593-4250
Practice Address - Fax:585-593-2465
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173875-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01080175Medicaid
NY173875OtherLICENSE
NY12118AMedicare ID - Type Unspecified
NY01080175Medicaid