Provider Demographics
NPI:1679693576
Name:VRIESENDORP, HUIBERT MICHIEL (MD, PH D)
Entity type:Individual
Prefix:DR
First Name:HUIBERT
Middle Name:MICHIEL
Last Name:VRIESENDORP
Suffix:
Gender:M
Credentials:MD, PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STRATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1650
Mailing Address - Country:US
Mailing Address - Phone:131-529-9698
Mailing Address - Fax:
Practice Address - Street 1:100 STRATHMORE DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-1650
Practice Address - Country:US
Practice Address - Phone:131-529-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223451-12085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB69829Medicare UPIN