Provider Demographics
NPI:1821083676
Name:KING, FREDERICK DOUGLAS II (PHD PT)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:DOUGLAS
Last Name:KING
Suffix:II
Gender:M
Credentials:PHD PT
Other - Prefix:MR
Other - First Name:FRED
Other - Middle Name:D
Other - Last Name:KING
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:PHD PT
Mailing Address - Street 1:2486 N PONDEROSA DR
Mailing Address - Street 2:STE D106
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2376
Mailing Address - Country:US
Mailing Address - Phone:805-484-5447
Mailing Address - Fax:805-484-2158
Practice Address - Street 1:2486 N PONDEROSA DR
Practice Address - Street 2:STE D106
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2376
Practice Address - Country:US
Practice Address - Phone:805-484-5447
Practice Address - Fax:805-484-2158
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT005390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S94817Medicare UPIN
CAWPT5390AMedicare ID - Type Unspecified