Provider Demographics
NPI:1578543260
Name:FREDIEU, ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:FREDIEU
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 1:1245 S UTICA AVE
Mailing Address - Street 2:3RD FLOOR WEST
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4214
Mailing Address - Country:US
Mailing Address - Phone:918-560-3823
Mailing Address - Fax:918-579-2535
Practice Address - Street 1:1245 S UTICA AVE
Practice Address - Street 2:3RD FLOOR WEST
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4214
Practice Address - Country:US
Practice Address - Phone:918-560-3823
Practice Address - Fax:918-579-2535
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP53642084N0400X
OK313652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010176026Medicaid
VA180288OtherANTHEM BCBS
OK200590450AMedicaid
VA001746276OtherMOUNTAIN STATE BCBS
WV3810002589Medicaid
VAP00235877OtherRAILROAD MEDICARE
VAH55027Medicare UPIN
VA010176026Medicaid