Provider Demographics
NPI:1134204050
Name:MAKDISSI, ANTOINE (MD)
Entity type:Individual
Prefix:
First Name:ANTOINE
Middle Name:
Last Name:MAKDISSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GATES CIR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1120
Mailing Address - Country:US
Mailing Address - Phone:716-887-4069
Mailing Address - Fax:
Practice Address - Street 1:3 GATES CIR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1120
Practice Address - Country:US
Practice Address - Phone:716-887-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4722207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00345147OtherRAILROAD MEDICARE 1
NY2215941OtherINDEPENDENT HEALTH
NY03182625Medicaid
NY2215941OtherINDEPENDENT HEALTH
NYJ400012293Medicare PIN