Healthcare Provider Details

I. General information

NPI: 1154382158
Provider Name (Legal Business Name): MICHAEL A FRUMKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NEWPORT WAY
SAN RAFAEL CA
94901-4411
US

IV. Provider business mailing address

30 NEWPORT WAY
SAN RAFAEL CA
94901-4411
US

V. Phone/Fax

Practice location:
  • Phone: 315-415-6865
  • Fax:
Mailing address:
  • Phone: 315-415-6865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number124060
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG89133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: