Provider Demographics
NPI:1558330563
Name:PARHAM, FRED WALTON (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:WALTON
Last Name:PARHAM
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 1:426 CORTE BARCELONA
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2112
Mailing Address - Country:US
Mailing Address - Phone:707-448-6909
Mailing Address - Fax:
Practice Address - Street 1:1000 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-447-3600
Practice Address - Fax:707-446-6515
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43938207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G439383Medicaid
A49500Medicare UPIN
00G439383Medicare ID - Type Unspecified