Provider Demographics
NPI:1093766412
Name:WIRTH, PAUL B (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:B
Last Name:WIRTH
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 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:425 ESSJAY RD STE 180
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-630-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179282-1207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161000580OtherNOVA
NY161000580OtherNORTH AMERICAN PREFERRED
NY01480299Medicaid
NY070008309OtherRR MEDICARE
NY0021748OtherGHI
NY000523271001OtherHEALTH NOW
NY0306229OtherIHA
NY179282-9WOtherWORKERS COMPENSATION
NY161000580OtherEMPIRE
NY00010190601OtherUNIVERA
NY161000580OtherNORTH AMERICAN PREFERRED
NYH52746Medicare PIN