Provider Demographics
NPI:1326013723
Name:PIETAK, KATHYLYNN C (MD)
Entity Type:Individual
Prefix:
First Name:KATHYLYNN
Middle Name:C
Last Name:PIETAK
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 1:6000 N BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5102
Mailing Address - Country:US
Mailing Address - Phone:716-834-4266
Mailing Address - Fax:716-834-6255
Practice Address - Street 1:6000 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-5102
Practice Address - Country:US
Practice Address - Phone:716-834-4266
Practice Address - Fax:716-834-6255
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY145444BJOtherPREFERRED CARE
NY040426002676OtherFIDELIS
NY00010491902OtherUNIVERA
NY000525623002OtherBC/BS
NY01970263Medicaid
NY0410911OtherIHA
G88840Medicare UPIN
NY01970263Medicaid