Healthcare Provider Details

I. General information

NPI: 1114043320
Provider Name (Legal Business Name): FREDERICK HASEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CASA ST SUITE 203
SAN LUIS OBISPO CA
93405-5803
US

IV. Provider business mailing address

4889 CHERRY AVE
SANTA MARIA CA
93455-4951
US

V. Phone/Fax

Practice location:
  • Phone: 805-544-6471
  • Fax:
Mailing address:
  • Phone: 805-937-0465
  • Fax: 805-597-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG28713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: