Provider Demographics
NPI:1922600345
Name:FREDRICK, JOHN C (LPO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9259 LAKE FISCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:GOTHA
Mailing Address - State:FL
Mailing Address - Zip Code:34734-5204
Mailing Address - Country:US
Mailing Address - Phone:850-247-8975
Mailing Address - Fax:
Practice Address - Street 1:9259 LAKE FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:GOTHA
Practice Address - State:FL
Practice Address - Zip Code:34734-5204
Practice Address - Country:US
Practice Address - Phone:850-247-8975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR13335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier