Provider Demographics
NPI:1952498040
Name:FREDA, JOHN JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JEFFREY
Last Name:FREDA
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 1:111 EAST 210TH STREET
Mailing Address - Street 2:KLAU 3
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2140
Mailing Address - Country:US
Mailing Address - Phone:718-920-5501
Mailing Address - Fax:718-920-8543
Practice Address - Street 1:111 EAST 210TH STREET
Practice Address - Street 2:KLAU 3
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-5501
Practice Address - Fax:718-920-8543
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181761207L00000X
NJ25MA06267400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01454493Medicaid
NY025881Medicare ID - Type Unspecified
NY01454493Medicaid
NYA400057790Medicare PIN