Provider Demographics
NPI:1962408252
Name:FREDERICK, WAYNE AI (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:AI
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6138 31ST PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1502
Mailing Address - Country:US
Mailing Address - Phone:202-865-6237
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW
Practice Address - Street 2:STE 4000
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-6237
Practice Address - Fax:860-679-1390
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD309052086X0206X, 208600000X
CT041334208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010266505Medicaid
DC037841900Medicaid
MD410159600Medicaid