Provider Demographics
NPI:1003010919
Name:FREDERICKS, PETER DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DANIEL
Last Name:FREDERICKS
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 1:175 S UNION BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3126
Mailing Address - Country:US
Mailing Address - Phone:719-365-1950
Mailing Address - Fax:719-365-1951
Practice Address - Street 1:175 S UNION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-1950
Practice Address - Fax:719-365-1951
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COFF3091573207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54988764Medicaid
CO470219YLB8Medicare PIN
IN201083370Medicaid