Healthcare Provider Details

I. General information

NPI: 1902804214
Provider Name (Legal Business Name): FREDERICK WICKS BRAZDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 PERDIDO ST PATHOLOGY DEPT. 5TH FLOOR
NEW ORLEANS LA
70112-1393
US

IV. Provider business mailing address

1901 PERDIDO ST PATHOLOGY DEPT. 5TH FLOOR
NEW ORLEANS LA
70112-1393
US

V. Phone/Fax

Practice location:
  • Phone: 504-568-6031
  • Fax: 504-568-6037
Mailing address:
  • Phone: 504-568-6031
  • Fax: 504-568-6037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number011447
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: