Provider Demographics
NPI:1982752291
Name:HEIDRICH, FRED E (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:E
Last Name:HEIDRICH
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 34581
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1581
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:125 16TH AVE E
Practice Address - Street 2:CSB-4
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5211
Practice Address - Country:US
Practice Address - Phone:206-326-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016024207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8445900Medicaid
WA233042OtherL&I
WAG8881815Medicare PIN
WA233042OtherL&I
WA8445900Medicaid