Provider Demographics
NPI:1174599161
Name:FACER, JEFFERY TODD (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:TODD
Last Name:FACER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CENTER STREET
Mailing Address - Street 2:STE 1
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1804
Mailing Address - Country:US
Mailing Address - Phone:716-679-2233
Mailing Address - Fax:716-679-9698
Practice Address - Street 1:12 CENTER STREET
Practice Address - Street 2:STE 1
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1804
Practice Address - Country:US
Practice Address - Phone:716-679-2233
Practice Address - Fax:716-679-9698
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2321991207R00000X
NY0137521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02563651Medicaid
I13102Medicare UPIN
NYRA2809Medicare ID - Type Unspecified