Provider Demographics
NPI:1215934203
Name:FREDRICKSON, DANN J (MD)
Entity type:Individual
Prefix:
First Name:DANN
Middle Name:J
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 N OAK TRFY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4688
Mailing Address - Country:US
Mailing Address - Phone:816-453-0900
Mailing Address - Fax:816-453-6271
Practice Address - Street 1:5400 N OAK TRFY
Practice Address - Street 2:SUITE 200
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4688
Practice Address - Country:US
Practice Address - Phone:816-453-0900
Practice Address - Fax:816-453-6271
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G73400Medicare UPIN
MOMA3392006Medicare PIN