Basic Information
Provider Information | |||||||||
NPI: | 1235255167 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIPAOLA | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4225 GENESEE ST | ||||||||
Address2: |   | ||||||||
City: | CHEEKTOWAGA | ||||||||
State: | NY | ||||||||
PostalCode: | 142251994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7169065908 | ||||||||
FaxNumber: | 7162044061 | ||||||||
Practice Location | |||||||||
Address1: | 4949 HARLEM RD | ||||||||
Address2: |   | ||||||||
City: | AMHERST | ||||||||
State: | NY | ||||||||
PostalCode: | 142262500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7162043200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2007 | ||||||||
LastUpdateDate: | 01/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | MD430230 | PA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 390200000X | MD430230 | PA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207X00000X | MD430230 | PA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 35-094128 | OH | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 249572-1 | NY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2992098 | 05 | OH |   | MEDICAID | 01750783 | 05 | NY |   | MEDICAID |