Provider Demographics
NPI:1437117264
Name:PODLAS, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:PODLAS
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 1:6653 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5906
Mailing Address - Country:US
Mailing Address - Phone:716-204-4500
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-204-4500
Practice Address - Fax:716-204-4501
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01223069Medicaid
NYE68121Medicare UPIN
NY01223069Medicaid
NYCC0394Medicare PIN