Provider Demographics
NPI:1255361382
Name:FRADY, WALTER B (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:B
Last Name:FRADY
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 1:16 ST JOHNS MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5299
Mailing Address - Country:US
Mailing Address - Phone:904-794-5411
Mailing Address - Fax:907-794-4224
Practice Address - Street 1:16 ST JOHNS MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5299
Practice Address - Country:US
Practice Address - Phone:904-794-5411
Practice Address - Fax:907-794-4224
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
26762OtherBLUE CROSS/SHIELD
FL377674300Medicaid
FL377674300Medicaid
G03851Medicare UPIN