Healthcare Provider Details

I. General information

NPI: 1013112531
Provider Name (Legal Business Name): FRITZNER BOURDEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 AVENUE J
BROOKLYN NY
11210-4117
US

IV. Provider business mailing address

3305 AVENUE J
BROOKLYN NY
11210-4117
US

V. Phone/Fax

Practice location:
  • Phone: 718-377-3627
  • Fax: 718-377-3097
Mailing address:
  • Phone: 718-377-3627
  • Fax: 718-377-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number186752
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: