Provider Demographics
NPI:1578546610
Name:FREDERICK, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:FREDERICK
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 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215 - CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:512-231-5507
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-406-7315
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138882904Medicaid
TX83013KOtherBCBS
TX98085OtherSCOTT & WHITE
TX138882920Medicaid
TX113019102OtherFIRSTCARE
TX138882909Medicaid
TX138882919Medicaid
TX138882919Medicaid
TX83013KOtherBCBS
TX138882909Medicaid
TX352480YKXYMedicare PIN
TX138882920Medicaid
TX98085OtherSCOTT & WHITE