Provider Demographics
NPI:1548411960
Name:FREDERICK, PETER (RDO)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 NEWBURYPORT TPKE STE A3
Mailing Address - Street 2:
Mailing Address - City:ROWLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01969-2132
Mailing Address - Country:US
Mailing Address - Phone:978-948-7756
Mailing Address - Fax:
Practice Address - Street 1:144 NEWBURYPORT TPKE STE A3
Practice Address - Street 2:
Practice Address - City:ROWLEY
Practice Address - State:MA
Practice Address - Zip Code:01969-2132
Practice Address - Country:US
Practice Address - Phone:978-948-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1959156FX1800X
NH782156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6163440002Medicare NSC