Healthcare Provider Details

I. General information

NPI: 1679958805
Provider Name (Legal Business Name): JEREMY WILLIAM FRUTKIN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MCKEEL AVE
TARRYTOWN NY
10591-3428
US

IV. Provider business mailing address

65 MCKEEL AVE
TARRYTOWN NY
10591-3428
US

V. Phone/Fax

Practice location:
  • Phone: 914-671-0604
  • Fax:
Mailing address:
  • Phone: 914-671-0604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2387783
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: