Provider Demographics
NPI:1760538110
Name:FREDERICSON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FREDERICSON
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 1:300 PASTEUR DR
Mailing Address - Street 2:EDWARDS R105 MC 5341
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-725-7139
Mailing Address - Fax:650-498-7546
Practice Address - Street 1:900 BLAKE WILBUR DR
Practice Address - Street 2:FIRST FLOOR MC 5311
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2201
Practice Address - Country:US
Practice Address - Phone:650-725-7139
Practice Address - Fax:650-498-7546
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG67096208100000X, 2081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF43713Medicare UPIN