Provider Demographics
NPI:1205064037
Name:FRED H. NAGATA, D.P.M., INC.
Entity type:Organization
Organization Name:FRED H. NAGATA, D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:HISAO
Authorized Official - Last Name:NAGATA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:559-435-3039
Mailing Address - Street 1:1191 E HERNDON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3164
Mailing Address - Country:US
Mailing Address - Phone:559-435-3039
Mailing Address - Fax:559-435-1105
Practice Address - Street 1:1191 E HERNDON AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3164
Practice Address - Country:US
Practice Address - Phone:559-435-3039
Practice Address - Fax:559-435-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2516213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOOE25160Medicaid
CAT11368Medicare UPIN