Provider Demographics
NPI:1063408425
Name:FRALICK, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:FRALICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E VALENCIA MESA DR STE 310
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3800
Mailing Address - Country:US
Mailing Address - Phone:714-446-5200
Mailing Address - Fax:714-446-5524
Practice Address - Street 1:100 E VALENCIA MESA DR STE 310
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3800
Practice Address - Country:US
Practice Address - Phone:714-446-5200
Practice Address - Fax:714-446-5524
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42751207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29631Medicare UPIN
CAWA42751IMedicare PIN