Provider Demographics
NPI:1174571152
Name:PENQUE, MICHELLE DOLORES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DOLORES
Last Name:PENQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0260
Mailing Address - Fax:716-323-0294
Practice Address - Street 1:1001 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0260
Practice Address - Fax:716-323-0294
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2008032080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018522750001Medicaid
040426001461OtherFIDELIS
000524862001OtherBC/BS
3990839OtherIHA
00010310201OtherUNIVERA
NY01776672Medicaid
CC7186Medicare PIN
00010310201OtherUNIVERA