Healthcare Provider Details

I. General information

NPI: 1518048834
Provider Name (Legal Business Name): SEAN ADRIAN DWIGHT FREDERICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 MARKET ST
BOARDMAN OH
44512-3457
US

IV. Provider business mailing address

6505 MARKET ST
BOARDMAN OH
44512-3457
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-2363
  • Fax: 330-480-6359
Mailing address:
  • Phone: 330-480-2363
  • Fax: 330-480-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.086341
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: