Provider Demographics
NPI:1528056629
Name:HENDRICKSON, FREDERIC CHARLES (DO)
Entity type:Individual
Prefix:MR
First Name:FREDERIC
Middle Name:CHARLES
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 STATE ROUTE 500
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-9173
Mailing Address - Country:US
Mailing Address - Phone:419-399-2630
Mailing Address - Fax:419-782-8853
Practice Address - Street 1:11550 STATE ROUTE 500
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-9173
Practice Address - Country:US
Practice Address - Phone:419-399-2630
Practice Address - Fax:419-782-8853
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-5455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0853170Medicaid
OHHE0714171Medicare ID - Type Unspecified
OH0853170Medicaid