Provider Demographics
NPI:1851328520
Name:SOUTHWICK, FREDERICK S (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:S
Last Name:SOUTHWICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FREDERICK
Other - Middle Name:SEACREST
Other - Last Name:SOUTHWICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-392-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64085207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055417100Medicaid
B40918Medicare UPIN
FL68568ZMedicare PIN
FL68568Medicare ID - Type Unspecified