Provider Demographics
NPI:1457340689
Name:BERNDTSON, JEFFREY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BERNDTSON
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 1:6255 SHERIDAN DR
Mailing Address - Street 2:STE 108
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4825
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:3345 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1506
Practice Address - Country:US
Practice Address - Phone:716-656-4826
Practice Address - Fax:716-250-5981
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224211208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02280404Medicaid
020054350Medicare PIN
H57196Medicare UPIN