Healthcare Provider Details

I. General information

NPI: 1568534964
Provider Name (Legal Business Name): WILLIAM FONFEDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1472 53RD ST
BROOKLYN NY
11219-3948
US

IV. Provider business mailing address

1472 53RD ST
BROOKLYN NY
11219-3948
US

V. Phone/Fax

Practice location:
  • Phone: 718-438-2309
  • Fax:
Mailing address:
  • Phone: 718-438-2309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number188439
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: