Provider Demographics
NPI:1255400313
Name:FADEFF, CHRIS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:MICHAEL
Last Name:FADEFF
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 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 STOCKDALE HWY STE 103
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-3621
Practice Address - Country:US
Practice Address - Phone:661-324-6593
Practice Address - Fax:602-512-6516
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA065257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA880171651OtherTAX IDENTIFICATION
CAG71360Medicare UPIN
CA00A652570Medicare ID - Type Unspecified