Provider Demographics
NPI:1588686471
Name:YAUKOOLBODI, SAMRET (MD)
Entity type:Individual
Prefix:
First Name:SAMRET
Middle Name:
Last Name:YAUKOOLBODI
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 1:100 HIGH ST
Mailing Address - Street 2:STE B252
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1126
Mailing Address - Country:US
Mailing Address - Phone:716-852-1977
Mailing Address - Fax:716-859-7388
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-852-1977
Practice Address - Fax:716-859-7388
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1373512085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00025409601OtherUNIVERA
5608983OtherINDEPENDENT HEALTH
CRDRA1373513OtherWORKERS COMPENSATION
00025409602OtherUNIVERA
000525482004OtherBLUE SHIELD WESTERN NY
NY00486508Medicaid
300122352OtherRAILROAD MEDICARE
00025409601OtherUNIVERA
NY00486508Medicaid
300122352OtherRAILROAD MEDICARE