Provider Demographics
NPI:1144218819
Name:FREDERICKSON, KIRT (MD)
Entity type:Individual
Prefix:DR
First Name:KIRT
Middle Name:
Last Name:FREDERICKSON
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 1:60 NEWTOWN RD
Mailing Address - Street 2:UNIT 45
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6257
Mailing Address - Country:US
Mailing Address - Phone:203-739-7532
Mailing Address - Fax:203-796-7667
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7532
Practice Address - Fax:203-796-7667
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0403902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT300003622Medicare PIN
H44873Medicare UPIN
CTP00476062Medicare PIN
CTP00051457Medicare PIN
NYP00093976Medicare PIN
NY617S11Medicare PIN
CT300003328Medicare PIN