Provider Demographics
NPI:1184720393
Name:FREDI, JOSEPH L (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:L
Last Name:FREDI
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 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5740
Mailing Address - Country:US
Mailing Address - Phone:318-212-3858
Mailing Address - Fax:318-212-3958
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-212-3858
Practice Address - Fax:318-212-3958
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD18034207RC0000X
LA310926207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3049405Medicaid
LA2487442Medicaid
TNE50989Medicare UPIN