Provider Demographics
NPI:1699774992
Name:PICKLESIMER, FRED L JR (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:L
Last Name:PICKLESIMER
Suffix:JR
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 1:1355 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:214-237-1818
Mailing Address - Fax:844-751-9263
Practice Address - Street 1:706 GREEN VALLEY RD STE 104
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7043
Practice Address - Country:US
Practice Address - Phone:336-387-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37331207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64052657Medicaid
KY0085113Medicare PIN
KY0084017Medicare PIN
KYH18842Medicare UPIN
KY64052657Medicaid