Provider Demographics
NPI:1932177359
Name:LAFFERTY, FREDERIC W (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:W
Last Name:LAFFERTY
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 1:1611 S GREEN RD
Mailing Address - Street 2:#147
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-381-1142
Mailing Address - Fax:216-381-6459
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:#147
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121
Practice Address - Country:US
Practice Address - Phone:216-381-1142
Practice Address - Fax:216-381-6459
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23458207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090584Medicaid
OH0090584Medicaid
LA0118772Medicare ID - Type Unspecified