Provider Demographics
NPI:1871056002
Name:MCILWAIN, DEMETRA (MD)
Entity type:Individual
Prefix:DR
First Name:DEMETRA
Middle Name:
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DOAT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14211-1612
Mailing Address - Country:US
Mailing Address - Phone:716-892-2775
Mailing Address - Fax:716-597-0554
Practice Address - Street 1:21 DOAT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14211-1612
Practice Address - Country:US
Practice Address - Phone:716-892-2775
Practice Address - Fax:716-597-0554
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY319236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program