Provider Demographics
NPI:1235365586
Name:FRAIDENBURG, DUSTIN RYAN (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RYAN
Last Name:FRAIDENBURG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6138 LAKEVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-9098
Mailing Address - Country:US
Mailing Address - Phone:810-845-5969
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.131110207RP1001X
IL036131110207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine