Provider Demographics
NPI:1891765913
Name:FREDRICKSON, DAVID PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:FREDRICKSON
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 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-628-3832
Mailing Address - Fax:641-628-8894
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-628-3832
Practice Address - Fax:641-628-8894
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2184218Medicaid
IA0184218Medicaid
IA48892Medicare PIN
IA48892Medicare ID - Type UnspecifiedMEDICARE NUMBER
IA2184218Medicaid