Provider Demographics
NPI:1629027362
Name:FALLAVOLLITA, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:FALLAVOLLITA
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 1:3435 MAIN STREET
Mailing Address - Street 2:SUNY AT BUFFALO - BIOMEDICAL RESEARCH BLDG ROOM 349
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-3021
Mailing Address - Country:US
Mailing Address - Phone:716-829-2667
Mailing Address - Fax:
Practice Address - Street 1:3980 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1727
Practice Address - Country:US
Practice Address - Phone:716-882-6544
Practice Address - Fax:716-882-6833
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179057207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5807950OtherINDEPEDENT HEALTH
NY000511108005OtherHEALTH NOW
NY01242295Medicaid
060023958Medicare PIN
NYE93042Medicare UPIN
NY01242295Medicaid