Provider Demographics
NPI:1881213510
Name:FREGOSO, BRYAN PETER (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:PETER
Last Name:FREGOSO
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 1:406.5 LINWOOD AVE
Mailing Address - Street 2:APT B
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE BLDG 25
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA186833207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program