Healthcare Provider Details

I. General information

NPI: 1538513031
Provider Name (Legal Business Name): FREDDIE DONALD JOSEPH III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

IV. Provider business mailing address

4900 MUELLER BLVD SUITE 3S.066C
AUSTIN TX
78723-3079
US

V. Phone/Fax

Practice location:
  • Phone: 520-694-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10055833
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number74819
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: