Provider Demographics
NPI:1841257177
Name:MCLELLAN-DESAI, MARY ANGELA (MD)
Entity type:Individual
Prefix:
First Name:MARY ANGELA
Middle Name:
Last Name:MCLELLAN-DESAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:DESAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0488
Mailing Address - Country:US
Mailing Address - Phone:203-944-1940
Mailing Address - Fax:203-402-4192
Practice Address - Street 1:705 MAPLE RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14221-3291
Practice Address - Country:US
Practice Address - Phone:716-656-4077
Practice Address - Fax:716-458-0271
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229046207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461329Medicaid
H53520Medicare UPIN
NY008494418Medicaid