Provider Demographics
NPI:1710181110
Name:FRADLIS, KLARA (MD)
Entity Type:Individual
Prefix:
First Name:KLARA
Middle Name:
Last Name:FRADLIS
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 1:606 MICHELLE PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3041
Mailing Address - Country:US
Mailing Address - Phone:718-891-6500
Mailing Address - Fax:718-891-5198
Practice Address - Street 1:2829 OCEAN PKWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7858
Practice Address - Country:US
Practice Address - Phone:718-891-6500
Practice Address - Fax:718-891-5198
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210932207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01977857Medicaid
G75438Medicare UPIN
NY41C081Medicare ID - Type Unspecified