Provider Demographics
NPI:1134196728
Name:KLEMENTOWSKI, MARC KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:KENNETH
Last Name:KLEMENTOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5906
Mailing Address - Country:US
Mailing Address - Phone:716-204-4500
Mailing Address - Fax:716-204-4501
Practice Address - Street 1:6653 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5906
Practice Address - Country:US
Practice Address - Phone:716-204-4500
Practice Address - Fax:716-204-4501
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188748207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01795308Medicaid
NY01795308Medicaid