Provider Demographics
NPI:1003270331
Name:FRY, PHILLIP EDWARD JR (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EDWARD
Last Name:FRY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:EDWARD
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3 EVERGLADE CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3485
Mailing Address - Country:US
Mailing Address - Phone:575-420-3425
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1010
Practice Address - Country:US
Practice Address - Phone:619-532-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17583207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine