Provider Demographics
NPI:1245214907
Name:BURRIS, FREDRICK ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:ANTHONY
Last Name:BURRIS
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:PO BOX 2739
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2739
Mailing Address - Country:US
Mailing Address - Phone:707-463-8000
Mailing Address - Fax:707-462-1111
Practice Address - Street 1:246 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4533
Practice Address - Country:US
Practice Address - Phone:707-463-8000
Practice Address - Fax:707-462-1111
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33796208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C337960Medicaid
CA00C337960Medicare ID - Type Unspecified
CAA35383Medicare UPIN