Provider Demographics
NPI:1134117203
Name:CALLANAN, VINCENT P (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:CALLANAN
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 1:219 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-2006
Mailing Address - Country:US
Mailing Address - Phone:716-878-7368
Mailing Address - Fax:716-878-1234
Practice Address - Street 1:219 BRYANT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2006
Practice Address - Country:US
Practice Address - Phone:716-878-7368
Practice Address - Fax:716-878-1234
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252974207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02496202Medicaid
NY02496202Medicaid
H97250Medicare UPIN