=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588847545
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRED H NAGATA DPM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2007
-----------------------------------------------------
Last Update Date | 07/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1592 11TH ST SUITE B
-----------------------------------------------------
City | REEDLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93654-2938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-638-2568
-----------------------------------------------------
Fax | 559-638-2556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1191 E HERNDON AVE SUITE 101
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-435-3039
-----------------------------------------------------
Fax | 559-435-1105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FRED HISAO NAGATA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 559-435-3039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | E2516
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------