Provider Demographics
NPI:1225048168
Name:FREDERIKS, DAVID JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JONATHAN
Last Name:FREDERIKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:ROOM 4.512
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-444-5144
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:ROOM 4.512
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-444-5144
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036811208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001368118Medicaid
CT080001759Medicare ID - Type Unspecified
G59182Medicare UPIN