Healthcare Provider Details

I. General information

NPI: 1750117776
Provider Name (Legal Business Name): SHAWN LEE FRUGE PSY18275
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CLAY ST STE 600
OAKLAND CA
94612-1427
US

IV. Provider business mailing address

1300 CLAY ST STE 600
OAKLAND CA
94612-1427
US

V. Phone/Fax

Practice location:
  • Phone: 888-345-0934
  • Fax:
Mailing address:
  • Phone: 888-345-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPSY18275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: