Provider Demographics
NPI:1568465896
Name:WEBER, FREDERICK THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:THOMAS
Last Name:WEBER
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 1:1859 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6966
Mailing Address - Country:US
Mailing Address - Phone:386-758-0003
Mailing Address - Fax:386-755-7940
Practice Address - Street 1:1859 SW NEWLAND WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6966
Practice Address - Country:US
Practice Address - Phone:386-758-0003
Practice Address - Fax:386-755-7940
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME246192080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055611400Medicaid
FL055611400Medicaid
FLD84859Medicare UPIN