=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528079571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELVYN JOHN FROESE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5305 N FRESNO ST STE 108
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-6845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-222-5241
-----------------------------------------------------
Fax | 559-222-9586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5305 N FRESNO ST STE 108
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-6845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-222-5241
-----------------------------------------------------
Fax | 559-222-9586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | A24796
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------