Provider Demographics
NPI:1962935460
Name:FODERO, JESSE (MD)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:FODERO
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 1:4225 GENESEE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1994
Mailing Address - Country:US
Mailing Address - Phone:716-204-3200
Mailing Address - Fax:
Practice Address - Street 1:6934 WILLIAMS RD STE 600
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-3081
Practice Address - Country:US
Practice Address - Phone:716-204-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304141207P00000X, 207X00000X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery