Basic Information
| Provider Information | |||||||||
| NPI: | 1013282581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRADKIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JARED | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 QUEEN ANNE AVE N | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981092367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068618500 | ||||||||
| FaxNumber: | 2068618501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2012 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A135505 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD60663357 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.