Provider Demographics
NPI:1104189026
Name:FREDERICK, DAVID (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 N MO PAC EXPY STE 420
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3055
Mailing Address - Country:US
Mailing Address - Phone:512-482-0045
Mailing Address - Fax:512-476-9892
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019942207R00000X
GA074006207R00000X
TXR1963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine