Provider Demographics
NPI:1548464993
Name:CORDOVA, FREDY H (MD)
Entity type:Individual
Prefix:DR
First Name:FREDY
Middle Name:H
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FREDY
Other - Middle Name:H
Other - Last Name:CORDOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:766 HL ROSS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-367-6246
Practice Address - Fax:855-926-7383
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD204318207Q00000X
ARE-10275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2137654Medicaid
PR28430Medicare UPIN