Provider Demographics
NPI:1932124682
Name:FREDERICK, WILLIAM R (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
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 1:106 IRVING ST NW
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2993
Mailing Address - Country:US
Mailing Address - Phone:202-291-6423
Mailing Address - Fax:202-291-0691
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:SUITE 304
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2993
Practice Address - Country:US
Practice Address - Phone:202-291-6423
Practice Address - Fax:202-291-0691
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC4502207R00000X
VA0101051734207R00000X
MDD0007970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6235OtherBLUE CROSS BLUE SHIELD
DC02214300Medicaid
MD413758OtherCAREFIRST BC BS OF MD
DC02214300Medicaid
MD413758OtherCAREFIRST BC BS OF MD