Provider Demographics
NPI:1134506702
Name:KPANDEYENGE, TITY MAE (MD)
Entity Type:Individual
Prefix:
First Name:TITY
Middle Name:MAE
Last Name:KPANDEYENGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1573
Mailing Address - Country:US
Mailing Address - Phone:716-881-6191
Mailing Address - Fax:716-881-6247
Practice Address - Street 1:184 BARTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213
Practice Address - Country:US
Practice Address - Phone:716-348-3000
Practice Address - Fax:716-881-6247
Is Sole Proprietor?:No
Enumeration Date:2015-05-02
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT216140390200000X
NY299099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program