Provider Demographics
NPI:1164479473
Name:WOOD, FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WOOD
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 1:25405 HANCOCK AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-698-4600
Mailing Address - Fax:951-514-2542
Practice Address - Street 1:25405 HANCOCK AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-698-4600
Practice Address - Fax:951-514-2542
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64336174400000X
CAG643360207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G643360Medicaid
CA060042893Medicare PIN
CA00G643360Medicaid
CA00G643360Medicare PIN
CAF84693Medicare UPIN
060042893Medicare PIN