Provider Demographics
NPI:1629139837
Name:FRIDOVICH, MARK A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:FRIDOVICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 AULIKE ST
Mailing Address - Street 2:PH 2
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2740
Mailing Address - Country:US
Mailing Address - Phone:808-236-8237
Mailing Address - Fax:
Practice Address - Street 1:14 AULIKE ST
Practice Address - Street 2:PH 2
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2740
Practice Address - Country:US
Practice Address - Phone:808-236-8237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2775103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2775OtherPSYCHOLOGIST