Active NPI
Justin Fredericks, DO
- General Practice Physician
- San Diego, CA
National Provider Identifier
1487356176
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Physician
- License
- 02007896A
- Practice address
- 2841 Rendova Rd
San Diego, CA 92155-5779 - Phone
- (727) 742-6825
- NPI assigned
- Mar 20, 2023
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Physician | 208D00000X | 02007896A | IN | Primary |
Addresses
Primary practice location
2841 Rendova Rd
San Diego, CA 92155-5779
Mailing address
2841 Rendova Rd
San Diego, CA 92155-5490
Phone (727) 742-6825
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 02007896A | IN | MD | General Practice Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1679270400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1732492800000",
"number": "1487356176",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2841 RENDOVA RD",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921555490",
"telephone_number": "727-742-6825"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2841 RENDOVA RD",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921555779",
"telephone_number": "727-742-6825"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FREDERICKS",
"first_name": "JUSTIN",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2023-03-20",
"last_updated": "2024-11-25",
"certification_date": "2024-11-25",
"status": "A"
},
"taxonomies": [
{
"code": "208D00000X",
"taxonomy_group": "",
"desc": "General Practice",
"state": "IN",
"license": "02007896A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.