Provider Demographics
NPI:1235334822
Name:FREY, FAYNE LESLIE
Entity Type:Individual
Prefix:DR
First Name:FAYNE
Middle Name:LESLIE
Last Name:FREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAYNE
Other - Middle Name:L
Other - Last Name:FREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2 CROSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-2226
Mailing Address - Country:US
Mailing Address - Phone:845-348-0501
Mailing Address - Fax:
Practice Address - Street 1:2 CROSFIELD AVE
Practice Address - Street 2:SUITE 319
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-2226
Practice Address - Country:US
Practice Address - Phone:845-348-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174790207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE87575Medicare UPIN
81F022Medicare ID - Type Unspecified