Provider Demographics
NPI:1205884533
Name:BANIFATEMI, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:BANIFATEMI
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 1:908 NIAGARA FALLS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:705 MAPLE RD STE 300
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3291
Practice Address - Country:US
Practice Address - Phone:716-710-8266
Practice Address - Fax:716-710-8267
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262789207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03390076Medicaid
PAI 23633Medicare UPIN
NY03390076Medicaid