Basic Information
Provider Information | |||||||||
NPI: | 1962408252 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREDERICK | ||||||||
FirstName: | WAYNE | ||||||||
MiddleName: | AI | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6138 31ST PL NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200151502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028656237 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2041 GEORGIA AVE NW | ||||||||
Address2: | STE 4000 | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200600001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028656237 | ||||||||
FaxNumber: | 8606791390 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2005 | ||||||||
LastUpdateDate: | 09/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | MD30905 | DC | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | MD30905 | DC | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 041334 | CT | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 010266505 | 05 | VA |   | MEDICAID | 037841900 | 05 | DC |   | MEDICAID | 410159600 | 05 | MD |   | MEDICAID |