Healthcare Provider Details

I. General information

NPI: 1326130071
Provider Name (Legal Business Name): FRED B HOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MITCHELL BLVD STE 106
SAN RAFAEL CA
94903-2019
US

IV. Provider business mailing address

70 MITCHELL BLVD STE 106
SAN RAFAEL CA
94903-2019
US

V. Phone/Fax

Practice location:
  • Phone: 415-479-6000
  • Fax:
Mailing address:
  • Phone: 415-479-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG50415
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG50415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: