Provider Demographics
NPI:1861588469
Name:FREDERICK, JAMES E (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:FREDERICK
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 1:9 TOGGLETOWN LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1427 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4343
Practice Address - Country:US
Practice Address - Phone:315-798-8868
Practice Address - Fax:315-368-0195
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY146667Medicaid
NY146667Medicaid
RA6487Medicare PIN