Provider Demographics
NPI:1134140999
Name:FREDENBERG, MARY F (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:FREDENBERG
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 1:14155 N 83RD AVE
Mailing Address - Street 2:SUITE #110
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5639
Mailing Address - Country:US
Mailing Address - Phone:623-215-0911
Mailing Address - Fax:623-215-0912
Practice Address - Street 1:14155 N 83RD AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5639
Practice Address - Country:US
Practice Address - Phone:623-215-0911
Practice Address - Fax:623-215-0912
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16095207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99499Medicare UPIN
AZZ66038Medicare ID - Type Unspecified