Provider Demographics
NPI:1972768042
Name:GURSKE-DEPERIO, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GURSKE-DEPERIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 GENESEE ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1994
Mailing Address - Country:US
Mailing Address - Phone:716-906-5908
Mailing Address - Fax:
Practice Address - Street 1:5959 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2291
Practice Address - Country:US
Practice Address - Phone:716-821-4400
Practice Address - Fax:716-829-2138
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY251338207X00000X
FLME106411207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY251338OtherLICENSE NUMBER, STATE OF NEW YORK
NY390200000XOtherSTUDENT, HEALTH CARE
NY390200000XOtherSTUDENT, HEALTH CARE