Provider Demographics
NPI:1265469332
Name:FREDERICK, JOHN J (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3346 LENNON ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1015
Mailing Address - Country:US
Mailing Address - Phone:810-732-1919
Mailing Address - Fax:810-732-3740
Practice Address - Street 1:3346 LENNON RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1082
Practice Address - Country:US
Practice Address - Phone:810-732-1919
Practice Address - Fax:810-732-3740
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI51010075682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310B510660OtherBCBSM
MI300075605OtherRAILROAD MEDICARE
MI3321207Medicaid
MI0M32800008Medicare PIN
MI300075605OtherRAILROAD MEDICARE