Provider Demographics
NPI:1497855373
Name:ENDE, FREDERICK IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:IVAN
Last Name:ENDE
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 1:121 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4217
Mailing Address - Country:US
Mailing Address - Phone:804-733-8771
Mailing Address - Fax:804-733-1017
Practice Address - Street 1:121 S MARKET ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4217
Practice Address - Country:US
Practice Address - Phone:804-733-8771
Practice Address - Fax:804-733-1017
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABC83897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005861861Medicaid
VA250896OtherANTHEM BLUE CROSS
VAB08377Medicare UPIN
VA005861861Medicaid