Provider Demographics
NPI:1780115493
Name:FROEBEL, BEAU (MD)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:FROEBEL
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 1:989 SUMNER RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14040-9711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 FARM COLONY DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-5203
Practice Address - Country:US
Practice Address - Phone:716-484-6700
Practice Address - Fax:716-487-0166
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
PAMD472023207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06362867Medicaid
PA103854010Medicaid