Provider Demographics
NPI:1831979558
Name:DOFREDO, MICHELANGELO (NP)
Entity type:Individual
Prefix:
First Name:MICHELANGELO
Middle Name:
Last Name:DOFREDO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:DOFREDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP, RN
Mailing Address - Street 1:4537 EVEREST CIR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-2659
Mailing Address - Country:US
Mailing Address - Phone:714-402-1359
Mailing Address - Fax:
Practice Address - Street 1:6430 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1713
Practice Address - Country:US
Practice Address - Phone:562-731-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022101363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care