Healthcare Provider Details

I. General information

NPI: 1609879709
Provider Name (Legal Business Name): MARK LESTER FRUITERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 WASHINGTON AVE STE 300
ALBANY NY
12206-1098
US

IV. Provider business mailing address

1365 WASHINGTON AVE STE 300
ALBANY NY
12206-1098
US

V. Phone/Fax

Practice location:
  • Phone: 518-489-4704
  • Fax: 518-489-0512
Mailing address:
  • Phone: 518-489-4704
  • Fax: 518-489-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number116938
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: