Healthcare Provider Details

I. General information

NPI: 1881798221
Provider Name (Legal Business Name): FREDERICK ALLEN RICHBURG II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 SORRENTO VALLEY BLVD SUITE 300
SAN DIEGO CA
92121-1432
US

IV. Provider business mailing address

6699 ALVARADO RD SUITE 2100
SAN DIEGO CA
92120-5238
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-7860
  • Fax: 858-436-1289
Mailing address:
  • Phone: 619-229-3909
  • Fax: 619-229-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA54679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: