Provider Demographics
NPI:1003995291
Name:FREDERICKSON, KIM S (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:S
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PROFESSIONAL CENTER DRIVE
Mailing Address - Street 2:SUITE 414
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947
Mailing Address - Country:US
Mailing Address - Phone:415-892-0754
Mailing Address - Fax:415-897-3204
Practice Address - Street 1:400 PROFESSIONAL CENTER DRIVE
Practice Address - Street 2:SUITE 414 NOVATO DERMATOLOGY ASSOCIATES
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947
Practice Address - Country:US
Practice Address - Phone:415-892-0754
Practice Address - Fax:415-897-3204
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79619207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G69391Medicare UPIN
00G796190Medicare ID - Type Unspecified
CA00G796191Medicare PIN