Provider Demographics
NPI:1730146226
Name:FREDERICKSON, ROBERT L (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:FREDERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:21048 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-0583
Mailing Address - Country:US
Mailing Address - Phone:660-827-2883
Mailing Address - Fax:660-827-1359
Practice Address - Street 1:3401 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2112
Practice Address - Country:US
Practice Address - Phone:660-827-2883
Practice Address - Fax:660-827-1359
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO36281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC50852Medicare UPIN
MO0685122Medicare ID - Type Unspecified