Basic Information
| Provider Information | |||||||||
| NPI: | 1558680611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOSTRACCO | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 267681 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04382789 | 05 | NY | MEDICAID |