Provider Demographics
NPI:1548443823
Name:FABREGA, ALFREDO JOSE
Entity type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:JOSE
Last Name:FABREGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 12TH ST STE 409
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-253-2262
Mailing Address - Fax:602-253-7191
Practice Address - Street 1:1300 N 12TH ST STE 409
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-253-2262
Practice Address - Fax:602-253-7191
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25884208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ402834Medicaid
AZZ21111Medicare PIN
AZ402834Medicaid