Basic Information
| Provider Information | |||||||||
| NPI: | 1417272246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRUCHTER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STANLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12450 VAN NUYS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188961161 | ||||||||
| FaxNumber: | 8188965069 | ||||||||
| Practice Location | |||||||||
| Address1: | 9418 LAGO DR | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334722752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615230351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 164771 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 6758 | 05 | CA | MEDICAID | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |