Provider Demographics
NPI:1275643348
Name:CLOSE, FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:CLOSE
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 1:5565 GROSSMONT CTR DR
Mailing Address - Street 2:BLDG 3 STE 156
Mailing Address - City:LAMESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-462-0900
Mailing Address - Fax:619-462-3584
Practice Address - Street 1:5565 GROSSMONT CTR DR
Practice Address - Street 2:BLDG 3 STE 156
Practice Address - City:LAMESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-462-0900
Practice Address - Fax:619-462-3584
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36625207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C366250Medicaid
CAC36625Medicare ID - Type Unspecified
CA00C366250Medicaid
A87868Medicare UPIN