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General NPI Number Information
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NPI Number | 1952747628
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Entity Type | Individual
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Provider Name | CHARLES FREDERICKS M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/21/2013
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 2315 STOCKTON BLVD
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City | SACRAMENTO
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State | CA
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Zip | 95817-2201
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Country | US
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Telephone | 916-734-5638
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Fax |
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Provider Business Mailing Address
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Address Line | 531 GRAPE ST
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City | HAMMONTON
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State | NJ
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Zip | 08037-1654
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 125-063161
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A161492
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License Number State | CA
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