Healthcare Provider Details

I. General information

NPI: 1629190905
Provider Name (Legal Business Name): JUDITH SUBEDI FREDERICKSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 VIRGINIA AVE
FRONT ROYAL VA
22630-2717
US

IV. Provider business mailing address

625 VIRGINIA AVE
FRONT ROYAL VA
22630-2717
US

V. Phone/Fax

Practice location:
  • Phone: 540-635-7991
  • Fax: 540-636-2516
Mailing address:
  • Phone: 540-635-7991
  • Fax: 540-636-2516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101057099
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: