Provider Demographics
NPI:1912329368
Name:TARIK ELIBOL, MD
Entity Type:Organization
Organization Name:TARIK ELIBOL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIBOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-876-4033
Mailing Address - Street 1:2949 ELMWOOD AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1356
Mailing Address - Country:US
Mailing Address - Phone:716-876-4033
Mailing Address - Fax:716-873-3085
Practice Address - Street 1:2949 ELMWOOD AVE
Practice Address - Street 2:STE 202
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1356
Practice Address - Country:US
Practice Address - Phone:716-876-4033
Practice Address - Fax:716-873-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-19
Last Update Date:2014-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102346-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024961Medicare PIN
NYB71161Medicare UPIN