Provider Demographics
NPI:1689897019
Name:GOUGH, FREDRIC (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:
Last Name:GOUGH
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 1:646 BROWN CT
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3940
Mailing Address - Country:US
Mailing Address - Phone:707-746-7663
Mailing Address - Fax:
Practice Address - Street 1:1200 B GALE WILSON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3552
Practice Address - Country:US
Practice Address - Phone:707-429-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40525207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF12575Medicare UPIN