Provider Demographics
NPI:1417992033
Name:FREDRIKSON, LORNA J (MD)
Entity Type:Individual
Prefix:
First Name:LORNA
Middle Name:J
Last Name:FREDRIKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10565 N TATUM BLVD
Mailing Address - Street 2:SUITE # B-116
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1095
Mailing Address - Country:US
Mailing Address - Phone:480-991-3203
Mailing Address - Fax:480-991-3997
Practice Address - Street 1:10565 N TATUM BLVD
Practice Address - Street 2:SUITE # B-116
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1095
Practice Address - Country:US
Practice Address - Phone:480-991-3203
Practice Address - Fax:480-991-3997
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24587207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ364597Medicaid
AZZ69280Medicare PIN
AZ364597Medicaid