Provider Demographics
NPI:1194827295
Name:WALBORN, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:WALBORN
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 1:893 COLVIN BLVD
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2423
Mailing Address - Country:US
Mailing Address - Phone:716-873-4406
Mailing Address - Fax:716-873-4420
Practice Address - Street 1:893 COLVIN BLVD
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2423
Practice Address - Country:US
Practice Address - Phone:716-873-4406
Practice Address - Fax:716-873-4420
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183082208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00010185504OtherUNIVERA
1703730OtherIHA
071227000043OtherFIDELIS
NY000511107004OtherBLUE CROSS
NY01257914Medicaid
1703730OtherIHA