Provider Demographics
NPI:1043528409
Name:WINSTON G DOUGLAS MD PC
Entity Type:Organization
Organization Name:WINSTON G DOUGLAS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:G
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-884-8033
Mailing Address - Street 1:755 WEHRLE DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1319
Mailing Address - Country:US
Mailing Address - Phone:716-884-8033
Mailing Address - Fax:716-906-3133
Practice Address - Street 1:755 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-1319
Practice Address - Country:US
Practice Address - Phone:716-884-8033
Practice Address - Fax:716-342-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03308216Medicaid