Basic Information
Provider Information
NPI: 1003801366
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MICHALEK
FirstName: LEO
MiddleName: MICHAEL
NamePrefix: DR.
NameSuffix: JR.
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 550 CENTER RD
Address2:  
City: WEST SENECA
State: NY
PostalCode: 14224
CountryCode: US
TelephoneNumber: 7166770100
FaxNumber: 7166770200
Practice Location
Address1: 561 RIDGE RD
Address2:  
City: LACKAWANNA
State: NY
PostalCode: 142181319
CountryCode: US
TelephoneNumber: 7168230141
FaxNumber: 7168225468
Other Information
ProviderEnumerationDate: 09/13/2005
LastUpdateDate: 05/05/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000X094920NYY Allopathic & Osteopathic PhysiciansGeneral Practice 

ID Information
IDTypeStateIssuerDescription
0001011840101 UNIVERAOTHER
00050533400101 BCBSOTHER
170029101 IHAOTHER
0060164305NY MEDICAID


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