Provider Demographics
NPI:1083689632
Name:FROST, JEFFREY BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRIAN
Last Name:FROST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 GLASSON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5706
Mailing Address - Country:US
Mailing Address - Phone:530-274-0200
Mailing Address - Fax:530-274-7722
Practice Address - Street 1:136 GLASSON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5706
Practice Address - Country:US
Practice Address - Phone:530-274-0200
Practice Address - Fax:530-274-7722
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G297110Medicaid
CA00G297110Medicare ID - Type Unspecified
CAA44124Medicare UPIN
CA00G297110Medicare PIN