Provider Demographics
NPI:1043297492
Name:FREDERICK, JOHN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 TANGLEFOOT LN
Mailing Address - Street 2:EYE SURGEONS ASSOCIATES PC
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-328-5694
Practice Address - Street 1:777 TANGLEFOOT LN
Practice Address - Street 2:EYE SURGEONS ASSOCIATES PC
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-323-2020
Practice Address - Fax:563-328-5694
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32467207W00000X, 207WX0110X
IL036-098033207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26568OtherIA GROUP MEDICARE
IL790730OtherIL GROUP MEDICARE
IA0060350OtherIA GROUP MEDICAID
IA0170860Medicaid
IL036098033Medicaid
IA26568OtherIA GROUP MEDICARE
IA0170860Medicaid
ILL64663Medicare PIN