Provider Demographics
NPI:1770508103
Name:WEBBER, FRED LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:LAWRENCE
Last Name:WEBBER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34681-0275
Mailing Address - Country:US
Mailing Address - Phone:727-742-2423
Mailing Address - Fax:
Practice Address - Street 1:20 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22801207Q00000X
WI19448207Q00000X
FLOS3587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E35762Medicare UPIN