Provider Demographics
NPI:1912953761
Name:TIBALLI, GERARD (DO)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:TIBALLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FOUNTAIN PLAZA
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2211
Mailing Address - Country:US
Mailing Address - Phone:716-691-8838
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:3980 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1727
Practice Address - Country:US
Practice Address - Phone:716-729-2800
Practice Address - Fax:716-929-2819
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176342207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01354049Medicaid
NY01354049Medicaid