Provider Demographics
NPI:1194392845
Name:FREDERICKSEN, BRETT WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:WILLIAM
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:833-776-2020
Mailing Address - Fax:208-297-2518
Practice Address - Street 1:291 N MILWAUKEE ST STE A-3
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9132
Practice Address - Country:US
Practice Address - Phone:833-776-2020
Practice Address - Fax:208-297-5718
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist