Healthcare Provider Details

I. General information

NPI: 1881798502
Provider Name (Legal Business Name): JAMES DENZIL FREDERICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 LIBERTY RD
WEST LIBERTY KY
41472
US

IV. Provider business mailing address

PO BOX 607
WEST LIBERTY KY
41472-0607
US

V. Phone/Fax

Practice location:
  • Phone: 606-743-3114
  • Fax: 606-743-1404
Mailing address:
  • Phone: 606-743-3114
  • Fax: 606-743-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16783
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: