Provider Demographics
NPI:1033217666
Name:FRETZ, STEPHANIE H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:H
Last Name:FRETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GARDENVILLE PKWY W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-857-6150
Mailing Address - Fax:716-656-4074
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1109
Practice Address - Country:US
Practice Address - Phone:716-878-2700
Practice Address - Fax:716-878-2701
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426001735OtherFIDELIS
NY00010057901OtherUNIVERA
NY01650600Medicaid
NY000523863001OtherBC/BS
NY1207908OtherINDEPENDENT HEALTH
NY01650600Medicaid
NY00010057901OtherUNIVERA