Provider Demographics
NPI:1356426712
Name:FREDRICKSON, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:FREDRICKSON
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 1:5514 PRESERVE CT
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-8510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3299 CLEAR VISTA CT NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-361-1200
Practice Address - Fax:616-361-2198
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMF048876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2836516Medicaid
080D148480OtherBCBS MICH
080D148480OtherBCBS MICH
MI2836516Medicaid