Provider Demographics
NPI:1932105640
Name:EDBAUER, MICHAEL JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:EDBAUER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 UNION RD
Mailing Address - Street 2:STE 8
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-1461
Mailing Address - Country:US
Mailing Address - Phone:716-206-1503
Mailing Address - Fax:716-651-9855
Practice Address - Street 1:3040 AMSDELL RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5835
Practice Address - Country:US
Practice Address - Phone:716-646-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181545208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426002674OtherFIDELIS
NY000528208005OtherBC/BS
NY1209831OtherINDEPEDENT HEALTH
NY00010050104OtherUNIVERA
NY01246139Medicaid
NY1209831OtherINDEPEDENT HEALTH
DD3770Medicare ID - Type Unspecified