Provider Demographics
NPI:1932385457
Name:NICHOLAS TIBERIA DPM
Entity Type:Organization
Organization Name:NICHOLAS TIBERIA DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-674-0375
Mailing Address - Street 1:100 UNION RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-4656
Mailing Address - Country:US
Mailing Address - Phone:716-674-0375
Mailing Address - Fax:
Practice Address - Street 1:100 UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-4656
Practice Address - Country:US
Practice Address - Phone:716-674-0375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003294-1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00742838Medicaid
NYT26087Medicare UPIN
NY00742838Medicaid
NY0972100001Medicare NSC