Basic Information
| Provider Information | |||||||||
| NPI: | 1003997800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8260 ATLEE RD | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047646300 | ||||||||
| FaxNumber: | 8047646562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101242098 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 0101242098 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12723963 | 01 | VA | CAQH | OTHER |