Basic Information
| Provider Information | |||||||||
| NPI: | 1780658112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 703 E MARSHALL AVE STE 5007 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033154455 | ||||||||
| FaxNumber: | 9033152466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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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 | 208800000X | K7155 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 145418306 | 05 | TX | MEDICAID | 145418307 | 05 | TX | MEDICAID | 75-2616977-007 | 01 | TX | TRICARE-DOUGLAS | OTHER | 752616977029 | 01 | TX | TRICARE ATHENS LOCATION | OTHER | 75-2616977-126 | 01 | TX | TRICARE | OTHER | 75-2616977-029 | 01 | TX | TRICARE | OTHER | 145418308 | 05 | TX | MEDICAID |