Provider Demographics
NPI:1225220262
Name:CABALLES, FREDERICK RYAN LOCSO (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:RYAN LOCSO
Last Name:CABALLES
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 1:40 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-1824
Mailing Address - Country:US
Mailing Address - Phone:732-367-8388
Mailing Address - Fax:
Practice Address - Street 1:720 GOVERNOR MORRISON ST
Practice Address - Street 2:SUITE 217
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3879
Practice Address - Country:US
Practice Address - Phone:704-243-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2010-01344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918645Medicaid
SCNC1480Medicaid
NCNC2364AMedicare PIN