Healthcare Provider Details

I. General information

NPI: 1962408252
Provider Name (Legal Business Name): WAYNE AI FREDERICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW STE 4000
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

6138 31ST PL NW
WASHINGTON DC
20015-1502
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-6237
  • Fax: 860-679-1390
Mailing address:
  • Phone: 202-865-6237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD30905
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD30905
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number041334
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: