1780658112 NPI number — DR. ROBERT W FREDERICK MD

Table of content: DR. ROBERT W FREDERICK MD (NPI 1780658112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780658112 NPI number — DR. ROBERT W FREDERICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
ROBERT
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780658112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 E MARSHALL AVE STE 5007
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-315-4455
Provider Business Practice Location Address Fax Number:
903-315-2466
Provider Enumeration Date:
02/14/2006

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: 208800000X , with the licence number:  K7155 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 145418306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145418307 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-2616977-007 . This is a "TRICARE-DOUGLAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 752616977029 . This is a "TRICARE ATHENS LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-126 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-2616977-029 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 145418308 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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