Provider Demographics
NPI:1013936608
Name:GREGORIUS, FREDERICK KARL (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:KARL
Last Name:GREGORIUS
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 1:2209 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5503
Mailing Address - Country:US
Mailing Address - Phone:209-943-0305
Mailing Address - Fax:209-943-0210
Practice Address - Street 1:2209 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5503
Practice Address - Country:US
Practice Address - Phone:209-943-0305
Practice Address - Fax:209-943-0210
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-2650763OtherTAX ID
CAA89233Medicare UPIN