Provider Demographics
NPI:1457569188
Name:DERY, FRED J JR (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:DERY
Suffix:JR
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 STEINDLER WAY STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-7907
Mailing Address - Country:US
Mailing Address - Phone:319-338-3606
Mailing Address - Fax:319-338-0522
Practice Address - Street 1:2301 STEINDLER WAY STE B
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-7907
Practice Address - Country:US
Practice Address - Phone:319-338-3606
Practice Address - Fax:319-338-0522
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA38968208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1457569188Medicaid
IAI75560005OtherMEDICARE PTAN