Provider Demographics
NPI:1972545184
Name:FRY, MICHAEL ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:FRY
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3404
Mailing Address - Fax:
Practice Address - Street 1:2333 BUCHANAN ST FL 2
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1925
Practice Address - Country:US
Practice Address - Phone:415-600-6455
Practice Address - Fax:415-600-2870
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG860802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G860800Medicaid
CAP00078726OtherRAILROAD MEDICARE
CA00G860802Medicare PIN
CA00G860804Medicare PIN
CAH41586Medicare UPIN
CA00G860803Medicare PIN
CAP00078726OtherRAILROAD MEDICARE