Provider Demographics
NPI:1295823680
Name:FRICKS, CARL ELLISON (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ELLISON
Last Name:FRICKS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 780
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-625-7200
Mailing Address - Fax:858-625-8363
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 780
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-625-7200
Practice Address - Fax:858-625-8363
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69384207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G693841Medicaid
CAF84402Medicare UPIN
CA00G693841Medicaid