Provider Demographics
NPI:1962490789
Name:FREDERICK, LOUIS A JR (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:A
Last Name:FREDERICK
Suffix:JR
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 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 100 NORTH
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1926
Mailing Address - Country:US
Mailing Address - Phone:804-288-6258
Mailing Address - Fax:804-282-9921
Practice Address - Street 1:5801 BREMO RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1907
Practice Address - Country:US
Practice Address - Phone:804-288-6258
Practice Address - Fax:804-282-9921
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045556207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5707781Medicaid
VA050001174Medicare ID - Type Unspecified
VA5707781Medicaid