Provider Demographics
NPI:1528124088
Name:FREDRICK, BRYAN D (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
Last Name:FREDRICK
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34451-0609
Mailing Address - Country:US
Mailing Address - Phone:352-341-3501
Mailing Address - Fax:
Practice Address - Street 1:121 S CITRUS AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452
Practice Address - Country:US
Practice Address - Phone:352-341-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0031083207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067905499Medicaid
FL95295UMedicare ID - Type Unspecified
FLD63403Medicare UPIN