Provider Demographics
NPI:1508894247
Name:POBLETE, FREDRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:
Last Name:POBLETE
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 1:1601 WHITEHORSE MERCERVILLE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3821
Mailing Address - Country:US
Mailing Address - Phone:609-586-1313
Mailing Address - Fax:609-584-9227
Practice Address - Street 1:1601 WHITEHORSE MERCERVILLE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3821
Practice Address - Country:US
Practice Address - Phone:609-586-1313
Practice Address - Fax:609-584-9227
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08013900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0102491Medicaid