Healthcare Provider Details

I. General information

NPI: 1508854258
Provider Name (Legal Business Name): FREDERICK FIBER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 EDITH BLVD NE
ALBUQUERQUE NM
87102-2509
US

IV. Provider business mailing address

401 EDITH BLVD NE
ALBUQUERQUE NM
87102-2509
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-8030
  • Fax: 505-842-1158
Mailing address:
  • Phone: 505-243-8030
  • Fax: 505-842-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number79-103
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: