Provider Demographics
NPI:1184618886
Name:FREDERICKS, DUANE (MD)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:FREDERICKS
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 1:530 1ST AVE
Mailing Address - Street 2:SK 10S
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-3166
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SK 10S
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-3166
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA089283002083P0901X, 207QB0002X
NYP40643208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery