Provider Demographics
NPI:1538192471
Name:FREDRICK, NOMI JUDITH (MD)
Entity type:Individual
Prefix:
First Name:NOMI
Middle Name:JUDITH
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NOMI
Other - Middle Name:JUDITH
Other - Last Name:FREDRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5810 RALSTON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5908
Mailing Address - Country:US
Mailing Address - Phone:310-923-5918
Mailing Address - Fax:805-642-7201
Practice Address - Street 1:5810 RALSTON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5908
Practice Address - Country:US
Practice Address - Phone:310-923-5918
Practice Address - Fax:805-642-7201
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG698552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E64994Medicare UPIN