Provider Demographics
NPI:1629035225
Name:FREDERICKSEN, GARY W (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 KINGS WAY
Practice Address - Street 2:SUITE 1300
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2505
Practice Address - Country:US
Practice Address - Phone:757-345-3001
Practice Address - Fax:757-345-3102
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618000905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist