Healthcare Provider Details

I. General information

NPI: 1811055940
Provider Name (Legal Business Name): FREDERIC B WILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEPUTY DEAN MIERA DR SW
ALBUQUERQUE NM
87151-1504
US

IV. Provider business mailing address

100 DEPUTY DEAN MIERA DR SW
ALBUQUERQUE NM
87151-1000
US

V. Phone/Fax

Practice location:
  • Phone: 505-839-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberAW1297894 XW1297894
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25744-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2023-1273
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: