Provider Demographics
NPI:1659390441
Name:CRUICKSHANK, FREDERICK A (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:A
Last Name:CRUICKSHANK
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 1:103 COMMERCE CENTRE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5869
Mailing Address - Country:US
Mailing Address - Phone:704-948-8582
Mailing Address - Fax:704-948-8572
Practice Address - Street 1:103 COMMERCE CENTRE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5869
Practice Address - Country:US
Practice Address - Phone:704-948-8582
Practice Address - Fax:704-948-8572
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01174207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2006-01174OtherSTATE LICENSE
NC5908056Medicaid
2072025Medicare PIN
NC5908056Medicaid