Provider Demographics
NPI:1144404526
Name:FREDERICK, MATTHEW ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
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 1:4515 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3699
Mailing Address - Country:US
Mailing Address - Phone:505-596-2200
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HIGHWAY
Practice Address - Street 2:UT MEDICAL CENTER
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920
Practice Address - Country:US
Practice Address - Phone:865-305-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2435-20207P00000X
390200000X
TN2145207P00000X
WAOP60257361207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program