Provider Demographics
NPI:1891769436
Name:POLISOTO, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:POLISOTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:338 HARRIS HILL RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7470
Mailing Address - Country:US
Mailing Address - Phone:716-634-4798
Mailing Address - Fax:716-634-0987
Practice Address - Street 1:550 ORCHARD PARK RD
Practice Address - Street 2:BUILDING C
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2646
Practice Address - Country:US
Practice Address - Phone:716-558-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174476-12081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01074657Medicaid
NYJ300031278Medicare PIN
NY250003022Medicare PIN
NY01074657Medicaid