Provider Demographics
NPI:1598721714
Name:LOGALBO, ELIZABETH MARIE (DO)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:LOGALBO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:RESZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:111 WALES AVE
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-2505
Mailing Address - Country:US
Mailing Address - Phone:716-633-7600
Mailing Address - Fax:716-633-7281
Practice Address - Street 1:256 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1901
Practice Address - Country:US
Practice Address - Phone:315-764-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01332874Medicaid
NYF34390Medicare UPIN
NY01332874Medicaid