Provider Demographics
NPI:1316933823
Name:FRICKER, EDWARD JOHN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
Last Name:FRICKER
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 1:3207 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1029
Mailing Address - Country:US
Mailing Address - Phone:229-242-8480
Mailing Address - Fax:229-247-7539
Practice Address - Street 1:3207 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1029
Practice Address - Country:US
Practice Address - Phone:229-242-8480
Practice Address - Fax:229-247-7539
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038487207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00610915AMedicaid
GA00610915AMedicaid
10BDHHJMedicare Oscar/Certification
GA10BBBRFMedicare ID - Type Unspecified
GAE55858Medicare UPIN