Provider Demographics
NPI:1538546304
Name:DOMRES, KAITLYN S (MD)
Entity type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:S
Last Name:DOMRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:SUE
Other - Last Name:DOMRES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4498 MAIN ST STE 23
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3826
Mailing Address - Country:US
Mailing Address - Phone:716-961-9424
Mailing Address - Fax:716-961-9950
Practice Address - Street 1:2465 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9407
Practice Address - Country:US
Practice Address - Phone:716-835-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295876207Q00000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program