Provider Demographics
NPI:1780658112
Name:FREDERICK, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:703 E MARSHALL AVE STE 5007
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601
Practice Address - Country:US
Practice Address - Phone:903-315-4455
Practice Address - Fax:903-315-2466
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7155208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145418306Medicaid
TX145418307Medicaid
TX75-2616977-007OtherTRICARE-DOUGLAS
TX752616977029OtherTRICARE ATHENS LOCATION
TX75-2616977-126OtherTRICARE
TX75-2616977-029OtherTRICARE
TX145418308Medicaid
TX752616977029OtherTRICARE ATHENS LOCATION
TX145418308Medicaid
TX75-2616977-029OtherTRICARE
H42794Medicare UPIN