Provider Demographics
NPI:1457328114
Name:BOMMARAJU, MAHESH (MD)
Entity Type:Individual
Prefix:
First Name:MAHESH
Middle Name:
Last Name:BOMMARAJU
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:716-878-7673
Mailing Address - Fax:716-878-7945
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-878-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1909002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000523290004OtherBC/BS
3610082OtherIHA
00010018901OtherUNIVERA
040426000926OtherFIDELIS
NY01564185Medicaid
NY01564185Medicaid
NYF80735Medicare UPIN