Provider Demographics
NPI:1508997248
Name:FREDERICK, TERRY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2505 W HAMILTON RD S
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9136
Mailing Address - Country:US
Mailing Address - Phone:260-625-6200
Mailing Address - Fax:260-625-6213
Practice Address - Street 1:2505 W HAMILTON RD S
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9136
Practice Address - Country:US
Practice Address - Phone:260-625-6200
Practice Address - Fax:260-625-6213
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01024046A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine