Provider Demographics
NPI:1467448514
Name:FREEMAN, AMY ILYSE (MD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ILYSE
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:ILYSE
Other - Last Name:KRUPNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12 EAST WILLOW STREET
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041
Mailing Address - Country:US
Mailing Address - Phone:973-376-8500
Mailing Address - Fax:973-376-1820
Practice Address - Street 1:12 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1417
Practice Address - Country:US
Practice Address - Phone:973-376-8500
Practice Address - Fax:973-376-1820
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 92169174400000X
NJ25MA08081300207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI35265Medicare UPIN
NJI35265Medicare UPIN
FLU5076ZMedicare ID - Type Unspecified