Provider Demographics
NPI:1174631899
Name:FREDERICKSON, BRADLEY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALAN
Last Name:FREDERICKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34719 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8714
Mailing Address - Country:US
Mailing Address - Phone:206-212-2100
Mailing Address - Fax:206-212-2194
Practice Address - Street 1:34719 6TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8714
Practice Address - Country:US
Practice Address - Phone:206-212-2100
Practice Address - Fax:206-212-2194
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0870427OtherAETNA GROUP PROVIDER NUMB
WA91162803298116A005OtherTRICARE & WPS BURIEN #
WA2017242Medicaid
WA2187FROtherREGENCE BURIEN RYDER #
WAFR5328OtherREGENCE AUBURN RYDER #
WA59460OtherL&I GROUP NUMBER
WA891451OtherCRIME VICTIMS GROUP NUMBE
WA911628032OtherBLUE CROSS BILLING ID #
WA91162803298002A003OtherTRICARE & WPS AUBURN #
WAFR8712OtherREGENCE FEDERAL WAY RYDER
WA2017259Medicaid
WA410028421OtherRAILROAD MEDICARE NUMBER
WA91162803298003A003OtherTRICARE & WPS FEDERAL WAY
WA59461OtherL & I INDIVIDUAL NUMBER
WAEV8144OtherREGENCE GROUP EEC #
WA91162803298002A003OtherTRICARE & WPS AUBURN #
WA91162803298003A003OtherTRICARE & WPS FEDERAL WAY
WA2017242Medicaid