Provider Demographics
NPI:1598723017
Name:DEZASTRO, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:DEZASTRO
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:PO BOX 8000
Mailing Address - Street 2:DEPT 836
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 GENESEE ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-855-2866
Practice Address - Fax:716-855-2860
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17812112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCRDRA178121OtherWORKERS COMPENSATION
P00003640OtherRAILROAD MEDICARE
000525009025OtherBLUE SHIELD OF WESTERN NY
145797FFOtherPREFERRED CARE
000525009022OtherBLUE SHIELD OF WESTERN NY
RB6952OtherMEDICARE
000525009016OtherBLUE SHIELD OF WESTERN NY
NY01607547Medicaid
300138602OtherRAILROAD MEDICARE
5609880OtherINDEPENDENT HEALTH
NY01607547Medicaid
P00003640OtherRAILROAD MEDICARE
CC4483Medicare PIN