MEDICARE: DR. TIMOTHY J FREDERIKSEN OD

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	152W00000X	Optometrist	2235-035	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649262478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY J FREDERIKSEN OD

Provider Business Mailing Address
First Line	:	1200 PARK CREEK CT
Second Line	:
City	:	FALL CREEK
State	:	WI
Zip	:	54742-5316
Country	:	US
Telephone Number	:	715-271-9899
Fax Number	:

Provider Business Practice Location Address
First Line	:	15569 RAILROAD ST
Second Line	:	STE 301
City	:	HAYWARD
State	:	WI
Zip	:	54843-5707
Country	:	US
Telephone Number	:	715-634-8616
Fax Number	:

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	01/09/2020

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