Basic Information
| Provider Information | |||||||||
| NPI: | 1790741304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRETWELL | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | ARLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633010 | ||||||||
| FaxNumber: | 5166633026 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633010 | ||||||||
| FaxNumber: | 5166633026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 190538 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01420828 | 05 | NY | MEDICAID | 51Z751 | 01 | MEDICARE | OTHER |