Provider Demographics
NPI:1699730341
Name:FREDERICKS, MICHAEL ROY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROY
Last Name:FREDERICKS
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 1:1040 MAIN ST
Mailing Address - Street 2:P.O. BOX 1360
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1816
Mailing Address - Country:US
Mailing Address - Phone:434-792-1433
Mailing Address - Fax:434-797-2807
Practice Address - Street 1:1040 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1816
Practice Address - Country:US
Practice Address - Phone:434-792-1433
Practice Address - Fax:434-797-2807
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233036207RN0300X
NC200300471207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7433254OtherCIGNA
384373OtherMAMSI
NC89065HOMedicaid
VA010131669Medicaid
VA171782OtherANTHEM
7433254OtherCIGNA
VA171782OtherANTHEM
H62772Medicare UPIN
NC89065HOMedicaid