Provider Demographics
NPI:1790828911
Name:FREDERICK, JOHN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
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 1:1200 5TH AVE STE 2010
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-3100
Mailing Address - Country:US
Mailing Address - Phone:206-778-5584
Mailing Address - Fax:
Practice Address - Street 1:1200 5TH AVE STE 2010
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-3100
Practice Address - Country:US
Practice Address - Phone:206-778-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000366322084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUS7536792OtherVM AETNA PCP PIN
WA0163635OtherVM LABOR AND INDUSTRIES #
WA3015FROtherVM BLUE SHIELD #
WA8286858Medicaid
WA8883129OtherMEDICARE - SNO CO
WAP00444827OtherVM RAILROAD MC #
WA8883129OtherMEDICARE - SNO CO
WAAB22833Medicare ID - Type UnspecifiedUW PHYSICIANS
WA8286858Medicaid
WAUS7536792OtherVM AETNA PCP PIN
WAP00444827OtherVM RAILROAD MC #