Provider Demographics
NPI:1649262478
Name:FREDERIKSEN, TIMOTHY J (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:FREDERIKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PARK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-5316
Mailing Address - Country:US
Mailing Address - Phone:715-271-9899
Mailing Address - Fax:
Practice Address - Street 1:15569 RAILROAD ST
Practice Address - Street 2:STE 301
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5707
Practice Address - Country:US
Practice Address - Phone:715-634-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2235-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38577900Medicaid
WI00720151Medicare ID - Type Unspecified
WI38577900Medicaid