Provider Demographics
NPI:1891898680
Name:FREDERICK, JEFFREY HOWARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HOWARD
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30005 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-1580
Mailing Address - Country:US
Mailing Address - Phone:248-514-2604
Mailing Address - Fax:
Practice Address - Street 1:30005 FOREST DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MI
Practice Address - Zip Code:48025-1580
Practice Address - Country:US
Practice Address - Phone:248-514-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJF001355213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1746737Medicaid
MI4279750001OtherMEDICARE DME
MI4279750001OtherNSC
480005115OtherMEDICARE RAILROAD
MI485635446OtherBCBS
DG9358OtherMEDICARE RAILROAD GROUP
MI382791635OtherTAX ID
MI382791635OtherTAX ID
MI0P39840001Medicare PIN
MI0P39840Medicare PIN