Provider Demographics
NPI:1063030690
Name:FREDRICK, JASON REGIS (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:REGIS
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 66TH RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2029
Mailing Address - Country:US
Mailing Address - Phone:718-830-4352
Mailing Address - Fax:
Practice Address - Street 1:10201 66TH RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2029
Practice Address - Country:US
Practice Address - Phone:718-830-4352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program