Provider Demographics
NPI:1043507866
Name:FREDERICK, LUKE RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:RICHARD
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:351 EXECUTIVE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5339
Mailing Address - Country:US
Mailing Address - Phone:815-398-4057
Mailing Address - Fax:815-398-0220
Practice Address - Street 1:351 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5339
Practice Address - Country:US
Practice Address - Phone:815-398-4057
Practice Address - Fax:815-398-0220
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140866208800000X
IL125.059642208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology