Provider Demographics
NPI:1396987277
Name:FREDERIKSEN, JOHN KARL (MD, PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KARL
Last Name:FREDERIKSEN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 S. WOOD ST.
Mailing Address - Street 2:130 CSN M/C 847
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-7312
Mailing Address - Fax:312-996-7586
Practice Address - Street 1:840 S. WOOD ST.
Practice Address - Street 2:130 CSN M/C 847
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-7312
Practice Address - Fax:312-996-7586
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.158028207ZP0102X
MI4301102278207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program