Provider Demographics
NPI:1568465458
Name:IBABAO, JAIRUS TESORERO (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIRUS
Middle Name:TESORERO
Last Name:IBABAO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3041 ORCHARD PARK RD STE C
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1238
Mailing Address - Country:US
Mailing Address - Phone:716-674-3104
Mailing Address - Fax:716-674-0666
Practice Address - Street 1:21 PORTER AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6247
Practice Address - Country:US
Practice Address - Phone:716-664-1909
Practice Address - Fax:716-664-2214
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2022-03-29
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Provider Licenses
StateLicense IDTaxonomies
NY193284207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY714714OtherMVP
NY005244934OtherBLUE CROSS BLUE SHIELD
NY7200341OtherGHI
NY830006548OtherRAILROAD MEDICARE
NY10352702OtherUNIVERA
NY0191329OtherINDEPENDENT HEALTH
NY1294660001OtherDME
NY01830340Medicaid
NY01830340Medicaid
NY714714OtherMVP
NY1294660001OtherDME