Provider Demographics
NPI:1275943987
Name:FREDERICK, DAVID (NMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 E GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3313
Mailing Address - Country:US
Mailing Address - Phone:602-421-2129
Mailing Address - Fax:
Practice Address - Street 1:1815 E GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3313
Practice Address - Country:US
Practice Address - Phone:602-421-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14-1434175F00000X
VT099.0102679175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath