Provider Demographics
NPI:1548270572
Name:FREDERICK, WILLIAM GHAVAMI (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GHAVAMI
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6305
Mailing Address - Street 2:CHURCH STREET STATION
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10249-6305
Mailing Address - Country:US
Mailing Address - Phone:800-214-2888
Mailing Address - Fax:207-753-2100
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706
Practice Address - Country:US
Practice Address - Phone:203-709-6053
Practice Address - Fax:203-709-3156
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029837207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E53405Medicare UPIN