Provider Demographics
NPI:1144281429
Name:FRETWELL, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FRETWELL
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 1:8906 135TH STREET
Mailing Address - Street 2:7L
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:718-206-7820
Mailing Address - Fax:718-206-6786
Practice Address - Street 1:8900 VAN WYCK EXPRESSWAY
Practice Address - Street 2:SURGICAL SUITE 1ST FLOOR
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-206-7110
Practice Address - Fax:718-206-7111
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190443208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01618666Medicaid
NY01618666Medicaid
G12236Medicare UPIN