Provider Demographics
NPI:1578036174
Name:FREGOLLE, MICHAEL MATTHEW (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:FREGOLLE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 BACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3237
Mailing Address - Country:US
Mailing Address - Phone:321-426-5688
Mailing Address - Fax:
Practice Address - Street 1:34520 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-2098
Practice Address - Country:US
Practice Address - Phone:619-532-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman