Healthcare Provider Details

I. General information

NPI: 1962689638
Provider Name (Legal Business Name): GERALD FREDMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

V. Phone/Fax

Practice location:
  • Phone: 505-837-9696
  • Fax:
Mailing address:
  • Phone: 505-837-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number76-172
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: