Provider Demographics
NPI:1649260118
Name:TIBERIA, NICHOLAS (DPM)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:TIBERIA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2574
Mailing Address - Country:US
Mailing Address - Phone:716-675-4417
Mailing Address - Fax:
Practice Address - Street 1:3085 SOUTHWESTERN BLVD
Practice Address - Street 2:STE 203
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1233
Practice Address - Country:US
Practice Address - Phone:716-674-0375
Practice Address - Fax:716-677-2965
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003294-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT26087Medicare UPIN