Healthcare Provider Details

I. General information

NPI: 1518964998
Provider Name (Legal Business Name): MARK J. FREDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK J FREDRICK MD

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19066 MAGNOLIA ST
HUNTINGTON BEACH CA
92646
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 714-968-0068
  • Fax: 714-378-2188
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG67380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: