Basic Information
| Provider Information | |||||||||
| NPI: | 1285614792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDSTROM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR | ||||||||
| Address2: | 3 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184249 | ||||||||
| FaxNumber: | 5413125230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR | ||||||||
| Address2: | C | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184249 | ||||||||
| FaxNumber: | 5413125230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD08366 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 063347 | 05 | OR | MEDICAID |