Provider Demographics
NPI:1073562716
Name:FUDYMA, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FUDYMA
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 1:2350 MAPLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4080
Mailing Address - Country:US
Mailing Address - Phone:716-688-6500
Mailing Address - Fax:716-688-6501
Practice Address - Street 1:2350 MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14221-4080
Practice Address - Country:US
Practice Address - Phone:716-688-6500
Practice Address - Fax:716-688-6501
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172763207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01205912Medicaid
NY00010058701OtherEXCELLUS UNIVERA
NY0407602OtherINDEPENDENT HEALTH
NY005108981OtherHEALTH NOW
NY0407602OtherINDEPENDENT HEALTH
NYE51409Medicare UPIN
NY01205912Medicaid