1629484902 NPI number — DR. FREDERICK HAROLD DO

Table of content: DR. FREDERICK HAROLD DO (NPI 1629484902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629484902 NPI number — DR. FREDERICK HAROLD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAROLD
Provider First Name:
FREDERICK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629484902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 E. 65TH STREET
Provider Second Line Business Mailing Address:
SUITE 22
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-7878
Provider Business Mailing Address Fax Number:
912-819-3320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
527 EISENHOWER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-819-9100
Provider Business Practice Location Address Fax Number:
912-819-9101
Provider Enumeration Date:
07/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34.012118 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 80159 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003207605A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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