Provider Demographics
NPI:1427078138
Name:SAMRA, AVTAR S (MD)
Entity type:Individual
Prefix:
First Name:AVTAR
Middle Name:S
Last Name:SAMRA
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 1:300 TWO MILE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6618
Mailing Address - Country:US
Mailing Address - Phone:716-447-6450
Mailing Address - Fax:716-447-6486
Practice Address - Street 1:300 TWO MILE CREEK RD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6618
Practice Address - Country:US
Practice Address - Phone:716-447-6450
Practice Address - Fax:716-447-6486
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189530208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000523654001OtherBLUE CROSS OF WNY
NY00010156101OtherUNIVERA HEALTHCARE
NY040426000412OtherFIDELIS
NY1207083OtherINDEPENDENT HEALTH
NY00010156101OtherUNIVERA HEALTHCARE
NYE67642Medicare ID - Type UnspecifiedMEDICARE B