Provider Demographics
NPI:1578606893
Name:FREDERICKA, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FREDERICKA
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 1:1753 E MARKET ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6672
Mailing Address - Country:US
Mailing Address - Phone:330-373-6903
Mailing Address - Fax:330-399-1055
Practice Address - Street 1:1753 E MARKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6672
Practice Address - Country:US
Practice Address - Phone:330-373-6903
Practice Address - Fax:330-399-1055
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040244207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411987Medicaid
OH0473602Medicare PIN