Healthcare Provider Details

I. General information

NPI: 1104997584
Provider Name (Legal Business Name): MARVIN P FRIED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MMC - DEPT. OF OTOLARYNGOLOGY 3400 BAINBRIDGE AVENUE, 3RD FL
BRONX NY
10467
US

IV. Provider business mailing address

320 W 86TH ST APT. 9B
NEW YORK NY
10024-3139
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2991
  • Fax:
Mailing address:
  • Phone: 718-920-2991
  • Fax: 718-944-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number213558
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: