Healthcare Provider Details

I. General information

NPI: 1679693576
Provider Name (Legal Business Name): HUIBERT MICHIEL VRIESENDORP M.D., PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STRATHMORE DR
SYRACUSE NY
13207-1650
US

IV. Provider business mailing address

100 STRATHMORE DR
SYRACUSE NY
13207-1650
US

V. Phone/Fax

Practice location:
  • Phone: 131-529-9698
  • Fax:
Mailing address:
  • Phone: 131-529-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number223451-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: