Provider Demographics
NPI:1417272246
Name:FRUCHTER, MICHAEL STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STANLEY
Last Name:FRUCHTER
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 1:12450 VAN NUYS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1393
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:9418 LAGO DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-2752
Practice Address - Country:US
Practice Address - Phone:561-523-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1647712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7068Medicaid
CA7420Medicaid