Provider Demographics
NPI:1578530242
Name:FREDRICKSON, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 81045
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-1045
Mailing Address - Country:US
Mailing Address - Phone:432-704-1696
Mailing Address - Fax:432-704-2130
Practice Address - Street 1:1800 HERITAGE BLVD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707
Practice Address - Country:US
Practice Address - Phone:432-520-1665
Practice Address - Fax:432-520-1666
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7056208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J35JMedicare PIN
TXF33100Medicare UPIN