Provider Demographics
NPI:1508966912
Name:DAVID M. WALBORN MD PC
Entity Type:Organization
Organization Name:DAVID M. WALBORN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WALBORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-873-4406
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 1:445 TREMONT ST
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6150
Practice Address - Country:US
Practice Address - Phone:716-873-4406
Practice Address - Fax:716-873-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE89592Medicare UPIN