Provider Demographics
NPI:1831419902
Name:KRAFT, FREDERICK BRUCE (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:BRUCE
Last Name:KRAFT
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 1:1481 SCHAEFFER RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-5542
Mailing Address - Country:US
Mailing Address - Phone:415-601-7858
Mailing Address - Fax:
Practice Address - Street 1:1429 W FREMONT ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2635
Practice Address - Country:US
Practice Address - Phone:209-546-7767
Practice Address - Fax:209-546-7785
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA485102083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48510OtherCA LICENSE