Provider Demographics
NPI:1801860630
Name:KREITZER, PHILIP R (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:KREITZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1226 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1155
Mailing Address - Country:US
Mailing Address - Phone:315-478-4185
Mailing Address - Fax:315-478-0840
Practice Address - Street 1:4211 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 211
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6637
Practice Address - Country:US
Practice Address - Phone:315-329-0210
Practice Address - Fax:315-329-0215
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY152920208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01843838Medicaid
B83014Medicare UPIN
56054EMedicare ID - Type Unspecified