Provider Demographics
NPI:1679872055
Name:SOUTHTOWNS GASTROENTEROLOGY, PLLC
Entity Type:Organization
Organization Name:SOUTHTOWNS GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ-ORDAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-677-9220
Mailing Address - Street 1:3065 SOUTHWESTERN BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1239
Mailing Address - Country:US
Mailing Address - Phone:716-677-9220
Mailing Address - Fax:716-677-9226
Practice Address - Street 1:3065 SOUTHWESTERN BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1239
Practice Address - Country:US
Practice Address - Phone:716-677-9220
Practice Address - Fax:716-677-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162503207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC57918Medicare UPIN