Provider Demographics
NPI:1134187537
Name:DEGRAVE, THOMAS EDWARD (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:DEGRAVE
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 1:10271 DARIEN RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14080-9628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3670 S BENZING RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1705
Practice Address - Country:US
Practice Address - Phone:716-662-5357
Practice Address - Fax:716-662-2774
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01789519Medicaid
NYE33583Medicare UPIN
NY01789519Medicaid