Provider Demographics
NPI:1669614798
Name:STORM, FREDERICK KRISTIAN III (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:KRISTIAN
Last Name:STORM
Suffix:III
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:S7698A LUCILLE LN
Mailing Address - Street 2:
Mailing Address - City:MERRIMAC
Mailing Address - State:WI
Mailing Address - Zip Code:53561-9793
Mailing Address - Country:US
Mailing Address - Phone:608-493-2767
Mailing Address - Fax:
Practice Address - Street 1:S7698A LUCILLE LN
Practice Address - Street 2:
Practice Address - City:MERRIMAC
Practice Address - State:WI
Practice Address - Zip Code:53561-9793
Practice Address - Country:US
Practice Address - Phone:608-493-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28443-020174400000X
WIBS8237390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist