Healthcare Provider Details

I. General information

NPI: 1053366633
Provider Name (Legal Business Name): DOUGLAS R. FREDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 HICKEY BLVD
DALY CITY CA
94015-2770
US

IV. Provider business mailing address

1800 HARRISON ST FL 7
OAKLAND CA
94612-3466
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-2000
  • Fax:
Mailing address:
  • Phone: 510-625-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License NumberA43821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: