Provider Demographics
NPI:1437133485
Name:FREDERICK, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 N CENTRO FAMILIAR SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105
Mailing Address - Country:US
Mailing Address - Phone:505-768-5450
Mailing Address - Fax:505-842-1185
Practice Address - Street 1:1316 BROADWAY SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-768-5450
Practice Address - Fax:505-842-1185
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM81191207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine