Provider Demographics
NPI:1548971831
Name:PAUL DEJAC PHYSICIAN PC
Entity type:Organization
Organization Name:PAUL DEJAC PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ACHTZIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-883-0515
Mailing Address - Street 1:656 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1836
Mailing Address - Country:US
Mailing Address - Phone:716-883-0515
Mailing Address - Fax:716-883-8764
Practice Address - Street 1:656 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1836
Practice Address - Country:US
Practice Address - Phone:716-883-0515
Practice Address - Fax:716-883-8764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty