Healthcare Provider Details

I. General information

NPI: 1447517461
Provider Name (Legal Business Name): JUSTIN FRIED M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2012
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

630 W 168TH ST
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-4600
  • Fax: 212-305-7439
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number279576
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number279576
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: