Provider Demographics
NPI:1790711810
Name:DEWIL, FREDERIC (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:DEWIL
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 1:1301 ROUTE 72 W STE 300
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2483
Mailing Address - Country:US
Mailing Address - Phone:609-597-6513
Mailing Address - Fax:609-597-4593
Practice Address - Street 1:1301 ROUTE 72 W STE 300
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2483
Practice Address - Country:US
Practice Address - Phone:609-597-6513
Practice Address - Fax:609-597-4593
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59306207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5556902Medicaid
NJP00297585OtherRAILROAD MEDICARE
NJF49803Medicare UPIN
743411Medicare ID - Type Unspecified
NJ5556902Medicaid