Healthcare Provider Details

I. General information

NPI: 1669436911
Provider Name (Legal Business Name): FRED WAYNE FRANKENBERG II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DATES DR
ITHACA NY
14850-1342
US

IV. Provider business mailing address

101 DATES DR
ITHACA NY
14850-1342
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-4011
  • Fax: 607-274-4198
Mailing address:
  • Phone: 607-274-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number81752
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number267226
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: