Provider Demographics
NPI:1083631022
Name:FERNHOLZ, FREDERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:
Last Name:FERNHOLZ
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 1:724 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-2742
Mailing Address - Country:US
Mailing Address - Phone:603-524-5151
Mailing Address - Fax:
Practice Address - Street 1:724 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-2742
Practice Address - Country:US
Practice Address - Phone:603-524-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7723208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30002198Medicaid
NHE42344Medicare UPIN
NHRE1047Medicare ID - Type Unspecified