Provider Demographics
NPI:1912984618
Name:POPE, FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:POPE
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 1:30 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0263
Mailing Address - Fax:860-263-0267
Practice Address - Street 1:30 JORDAN LN
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1278
Practice Address - Country:US
Practice Address - Phone:860-263-0263
Practice Address - Fax:860-263-0267
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT017871OtherMEDICAL LICENSE
CT001178714Medicaid
010017871CT02OtherBCBC CT
010017871CT02OtherBCBC CT
010017871CT02OtherBCBC CT
CTAP7010692OtherDEA