Provider Demographics
NPI:1962677138
Name:YENTZER, BRAD A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:YENTZER
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 1:2141 DRYDEN RD
Mailing Address - Street 2:
Mailing Address - City:FREEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13068-9611
Mailing Address - Country:US
Mailing Address - Phone:607-708-1330
Mailing Address - Fax:607-708-4242
Practice Address - Street 1:2141 DRYDEN RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-9611
Practice Address - Country:US
Practice Address - Phone:607-708-1330
Practice Address - Fax:607-708-4242
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287410207N00000X
ORMD161532207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657984Medicaid