Provider Demographics
NPI:1043335755
Name:FREDERICKS, LEROY E (MD)
Entity type:Individual
Prefix:DR
First Name:LEROY
Middle Name:E
Last Name:FREDERICKS
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:PO BOX 122579
Mailing Address - Street 2:DEPT 2579
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2579
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0404
Practice Address - Country:US
Practice Address - Phone:337-494-6768
Practice Address - Fax:337-494-6792
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD10005R207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491217Medicaid
LAMD.10005ROtherSTATE MEDICAL LICENSE
LA1491217Medicaid
LA5Y484DC96Medicare Oscar/Certification