Provider Demographics
NPI:1073931564
Name:FREUDZON, MARIANNA (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:FREUDZON
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 1:3495 PIEDMONT RD NE BLDG 91
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:333 CEDAR ST
Practice Address - Street 2:YUSM DEPARTMENT OF DERMATOLOGY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-4632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT60476207N00000X
390200000X
GA083125207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073931564OtherINDIVIDUAL