Provider Demographics
NPI:1346397239
Name:FREDERICK, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:398 ASHE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-1729
Mailing Address - Country:US
Mailing Address - Phone:256-383-1499
Mailing Address - Fax:
Practice Address - Street 1:398 ASHE BLVD
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-1729
Practice Address - Country:US
Practice Address - Phone:256-383-1499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL28212204E00000X
ALAL52711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery