Provider Demographics
NPI:1790108264
Name:JOHANNA S. FRICKE, M.D., LLC
Entity Type:Organization
Organization Name:JOHANNA S. FRICKE, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRICKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-804-9065
Mailing Address - Street 1:1300 PREMIER CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7134
Mailing Address - Country:US
Mailing Address - Phone:702-804-9065
Mailing Address - Fax:702-877-2521
Practice Address - Street 1:311 N BUFFALO DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0375
Practice Address - Country:US
Practice Address - Phone:702-877-2520
Practice Address - Fax:702-877-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2080P0006X, 261QD1600X, 261QM0855X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV32876OtherMEDICARE ID-TYPE UNSPECIFIED/MEDICARE
NV002002223Medicaid
NVCS09750OtherSTATE PHARMACY
NV003102223OtherMEDICARE ID-TYPE UNSPECIFIED/NV MEDICAID
NVFF3563221OtherDEA
NV002002223Medicaid