Provider Demographics
NPI:1376556613
Name:FRADLIS, IOSIF (MD)
Entity Type:Individual
Prefix:
First Name:IOSIF
Middle Name:
Last Name:FRADLIS
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 1:606 MICHELLE PLACE
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:516-791-5849
Mailing Address - Fax:
Practice Address - Street 1:2829 OCEAN PKWY STE 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7859
Practice Address - Country:US
Practice Address - Phone:718-891-6372
Practice Address - Fax:718-891-5198
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207428-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01890188Medicaid
NY58M101Medicare ID - Type Unspecified
NYG68257Medicare UPIN