Provider Demographics
NPI:1164564142
Name:FREY, CONRAD J (MD)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:J
Last Name:FREY
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 1:4550 SARATOGA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-2340
Mailing Address - Country:US
Mailing Address - Phone:619-517-8171
Mailing Address - Fax:
Practice Address - Street 1:4550 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-2340
Practice Address - Country:US
Practice Address - Phone:619-517-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A430870Medicaid
E66243Medicare UPIN