Healthcare Provider Details

I. General information

NPI: 1932083102
Provider Name (Legal Business Name): ANTHONY FREDERICKS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4516 JOE DAN PL NE
ALBUQUERQUE NM
87110-5043
US

IV. Provider business mailing address

4516 JOE DAN PL NE
ALBUQUERQUE NM
87110-5043
US

V. Phone/Fax

Practice location:
  • Phone: 760-707-8504
  • Fax:
Mailing address:
  • Phone: 760-707-8504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY FREDERICKS
Title or Position: OWNER
Credential: MD
Phone: 760-707-8504