Healthcare Provider Details

I. General information

NPI: 1043297492
Provider Name (Legal Business Name): JOHN CHARLES FREDERICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 TANGLEFOOT LN EYE SURGEONS ASSOCIATES PC
BETTENDORF IA
52722
US

IV. Provider business mailing address

777 TANGLEFOOT LN EYE SURGEONS ASSOCIATES PC
BETTENDORF IA
52722-1650
US

V. Phone/Fax

Practice location:
  • Phone: 563-323-2020
  • Fax: 563-328-5694
Mailing address:
  • Phone: 563-323-2020
  • Fax: 563-328-5694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number32467
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number036-098033
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number32467
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-098033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: