Healthcare Provider Details

I. General information

NPI: 1841280872
Provider Name (Legal Business Name): WILLIAM H FREDRIKSSON JR. MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 WALDEMERE ST STE 310
SARASOTA FL
34239-2941
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-5400
  • Fax: 941-917-5420
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberM8037
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME154478
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: