Provider Demographics
NPI:1982793808
Name:DAVID, FREDERICK CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:CHARLES
Last Name:DAVID
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 1:3555 ROUND BARN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1757
Mailing Address - Country:US
Mailing Address - Phone:707-528-1050
Mailing Address - Fax:707-576-0445
Practice Address - Street 1:3555 ROUND BARN CIRCLE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1757
Practice Address - Country:US
Practice Address - Phone:707-528-1050
Practice Address - Fax:707-576-0445
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG345982085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G345980Medicaid
00G345980Medicare ID - Type Unspecified
CA00G345980Medicaid