Healthcare Provider Details

I. General information

NPI: 1770568057
Provider Name (Legal Business Name): FREDERICK LUDWIG JARDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR SUITE 304
SOUTHFIELD MI
48075-4825
US

IV. Provider business mailing address

22250 PROVIDENCE DR SUITE 304
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-4366
  • Fax: 248-569-4614
Mailing address:
  • Phone: 248-569-4366
  • Fax: 248-569-4614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301028741
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: