Provider Demographics
NPI:1962689638
Name:FREDMAN, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:FREDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 INDIAN SCHOOL RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2653
Mailing Address - Country:US
Mailing Address - Phone:505-837-9696
Mailing Address - Fax:
Practice Address - Street 1:2741 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2653
Practice Address - Country:US
Practice Address - Phone:505-837-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76-1722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry