1902965742 NPI number — BRIAN PAUL FREDERICK PH.D.

Table of content: BRIAN PAUL FREDERICK PH.D. (NPI 1902965742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902965742 NPI number — BRIAN PAUL FREDERICK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
BRIAN
Provider Middle Name:
PAUL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1902965742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 MILL POND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70592-5655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 KALISTE SALOOM RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-237-0788
Provider Business Practice Location Address Fax Number:
337-237-0785
Provider Enumeration Date:
12/07/2006

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: 103T00000X , with the licence number:  880 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 40-005 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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