Provider Demographics
NPI:1275976953
Name:FREDERICK, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:FREDERICK
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 1:4168 HIGHLANDS CIR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2800
Mailing Address - Country:US
Mailing Address - Phone:256-783-4990
Mailing Address - Fax:
Practice Address - Street 1:4168 HIGHLANDS CIR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-2800
Practice Address - Country:US
Practice Address - Phone:256-783-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program