Provider Demographics
NPI:1720100340
Name:FREDERICK, WINSTON RAPHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:RAPHAEL
Last Name:FREDERICK
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:PO BOX 644
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20848
Mailing Address - Country:US
Mailing Address - Phone:240-899-0401
Mailing Address - Fax:202-526-5035
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:DEPAUL BLDG SUITE 016
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-526-6442
Practice Address - Fax:202-526-5035
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD14686207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
C87931Medicare UPIN
012342H13Medicare ID - Type Unspecified