Provider Demographics
NPI:1982636783
Name:FREDERICK, LAURA (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 MAIN ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3798
Mailing Address - Country:US
Mailing Address - Phone:703-764-3937
Mailing Address - Fax:703-764-3986
Practice Address - Street 1:9600 MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3798
Practice Address - Country:US
Practice Address - Phone:703-764-3937
Practice Address - Fax:703-764-3986
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001477152W00000X
FLOPC3889152W00000X
MDTA1945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDV01816Medicare UPIN
MD747LP945Medicare PIN