MEDICARE: DR. FREDERICK DAVID WAX M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	43674	MA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070009900	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	J20061	OTHER	MA	BLUECROSS/BLUESHIELD OF MASSACHUSETTS

General Provider Information

NPI Number	:	1275545089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK DAVID WAX M.D.

Provider Business Mailing Address
First Line	:	345 COURT ST
Second Line	:	SUITE 201
City	:	PLYMOUTH
State	:	MA
Zip	:	02360-4329
Country	:	US
Telephone Number	:	508-747-0050
Fax Number	:	508-747-2001

Provider Business Practice Location Address
First Line	:	345 COURT ST
Second Line	:	SUITE 201
City	:	PLYMOUTH
State	:	MA
Zip	:	02360-4329
Country	:	US
Telephone Number	:	508-747-0050
Fax Number	:	508-747-2001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	05/07/2008

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