Provider Demographics
NPI:1104962737
Name:PEDIATRIC UROLOGY OF WESTERN NEW YORK P C
Entity type:Organization
Organization Name:PEDIATRIC UROLOGY OF WESTERN NEW YORK P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-859-7978
Mailing Address - Street 1:65 LEBRUN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:EGGERTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4120
Mailing Address - Country:US
Mailing Address - Phone:716-878-7393
Mailing Address - Fax:716-878-7096
Practice Address - Street 1:100 HIGH ST, #C2
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-859-7978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231942208800000X
NY1415412088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01376347Medicaid
NY01376347Medicaid