Provider Demographics
NPI:1528601283
Name:ROMAN, CALEEK PEDRO MARKUS
Entity Type:Individual
Prefix:
First Name:CALEEK
Middle Name:PEDRO MARKUS
Last Name:ROMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1102
Mailing Address - Country:US
Mailing Address - Phone:716-881-2405
Mailing Address - Fax:716-881-2425
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1102
Practice Address - Country:US
Practice Address - Phone:716-881-2405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC744747864-00Medicaid